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.     

Violence in New South Wales emergency departments.

In 1999 the International Council of Nurses recognised workplace violence as a significant issue in nursing. During the same year the Australian Institute of Criminology reported that health was the most violent industry. This study examined the nature and extent of violence in NSW hospital emergency departments. Emergency nurses experienced violent incidents in their department, in the wards and outside the hospital setting. Every respondent (n=266) experienced some form of violence at least weekly. Ninety-two incidents involved lethal weapons. Ninety-two percent of perpetrators were patients or their relatives, however other staff members were also implicated. Non-reporting of violence is an issue as over 70% of incidents were not referred to authorities. Drugs, alcohol and emergency department waiting times are the most significant predisposing factors. Most emergency nurses are not satisfied with the response of administration to violent incidents within hospitals.     

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.     

Violence in the emergency department: an ethnographic study (part II)

Violence in the emergency department (ED) is a significant and complex problem worldwide. This is a part II of a 2-part series on an ethnographic study. The study which aimed at exploring the cultural aspects of violence was carried out at a major metropolitan ED for 3 months. This paper presents the findings and discussions of the study. One hundred and three violent incident questionnaires were completed. A total of 242.5h of observation and 34 (33%) interviews with nurses were conducted. From the data analysis, three critical cultural themes (i.e. 'problems and solutions', 'requests and demands' and 'them and us') were identified. The study indicated that the cultural meanings of violence were complex and highly subjective. Factors such as environment, conflicting messages regarding waiting time, and the nurse-patient/relative behaviours and the resulting reciprocal relationships were critical. Nurses' efforts to establish rapport with patients was crucial and needed to occur early. There was usually a 'turning point' that provided an opportunity for the nurse to avoid violence. While violence is a complex issue with many paradoxes, the study indicates that effective interpersonal empathetic communication has a significant role in reducing violence in the ED.     

Violence in mental health care: the experiences of mental health nurses and psychiatrists

Violence against mental health service personnel is a serious workplace problem and one that appears to be increasing. This study aimed to ascertain the extent and nature of violence against mental health nurses and psychiatrists, and to identify what support, if any, they received following exposure to violence. Mental health staff working within five West Midlands Trusts in the United Kingdom were surveyed using a postal questionnaire to investigate the extent and nature of violence they encountered in their daily work. There was an overall response rate of 47%, which included a response rate for psychiatrists of 60% (n=74) and for mental health nurses of 45% (n=301). Though both groups experienced violence at work, nurses were found: to have been exposed to violence significantly more during their career; to have been a victim of violence within the previous 12 months of the survey; and to have suffered a violent incident involving physical contact. Whilst a higher proportion of nurses than psychiatrists received some support following a violent incident, a large proportion of both groups did not receive any, although most felt in need of it. The implications of this study for training and management are discussed.     

An association between occupancy rates in the emergency department and rates of violence toward staff

Background

Studies have explored possible causes of violent acts in the emergency department (ED), however, the association of violence with ED crowding has not been studied. Although the total number of violent acts would be expected to increase, it is not clear if the rate of violent acts also increases as occupancy levels rise.

Objective

The purpose of this study was to determine if there is an association between occupancy rates in the ED and rates of violence toward staff.

Methods

This was a retrospective chart review study. Violent incidents in a community, Level I trauma center ED were identified from review of orders of emergency detainment, adverse event forms, physical restraint logs, and pharmacy records from January 1, 2005 to June 1, 2008. Occupancy rates for all days were calculated and violent vs. non-violent days were compared using a standard two-sample t-test. Logistic regression analysis was then used to investigate other factors associated with violent incidents.

Results

A rate of violence of 1.3 incidents per 1000 patients was found. When comparing the occupancy rates of violent days (mean 95%, SD 26%) with non-violent days (mean 86%, SD 24%), a statistically significant association was found (p < 0.0001). Multivariate logistic regression confirmed a significant association between crowding and violence toward staff (odds ratio 4.290, 95% confidence interval 2.137–8.612).

Conclusion

These results suggest another possible negative effect that crowding has on ED staff and physicians. Policies and recommendations regarding ED operating procedures and staff safety during times of higher occupancy levels should be discussed.     

Factors affecting Israeli nurses' reports of violence perpetrated against them in the workplace: A test of the theory of planned behaviour

Ben Natan M, Hanukayev A, Fares S. International Journal of Nursing Practice 2011; 17 : 141–150 Factors affecting Israeli nurses' reports of violence perpetrated against them in the workplace: A test of the theory of planned behaviour Violence against nurses in the workplace is universal. Violence has negative implications for nurses, their patients and the medical facility. Nonetheless, violent incidents are only infrequently reported (20–25%). A correlational design was used to examine whether the guiding conceptual model, constructed of the variables: assailant traits, victim traits and type of violence, succeeds in predicting a nurse's decision to report violence perpetrated against them in the workplace. Data were gathered with a structured questionnaire, constructed specifically for the current research and based on the literature review and research model. The research population was sampled by convenience sampling and consisted of nurses from general hospitals in northern and central Israel of 220 nurses, of whom nearly 72% (n = 158) had experienced violent incidents over the past year, mainly verbal abuse by patients' relatives. Only 26.6% (n = 42) reported violent incidents in written form. Most reports were submitted to the nurse in charge of the department. Correlations were found between assailant traits (identity and mental state) and victim traits (sociodemographic characteristics and attitudes on and perceptions of reporting) and intention and actual report. Nurses' normative beliefs regarding reporting violence had the greatest effect on intention to report.     

Domestic Abuse in the Emergency Department: Can a Risk Profile Be Defined?

OBJECTIVES: The main purpose of this study was to determine whether any clinical or demographic characteristics could identify adult female patients presenting to the emergency department (ED) with a history of domestic abuse. A second objective was to describe the frequency, types, and severity of this abuse. METHODS: This study was a crosssectional survey of 611 women conducted in an academically-affiliated, urban ED. Domestic abuse was described as "recent" (within the preceding 12 months) or "lifetime" (recent or past). This included emotional, physical, and sexual abuse. RESULTS: Recent (7.9%, n = 48) and lifetime (38%, n = 232) domestic abuse was reported. For recently abused women, violence had been severe (87.5%, n = 42) and was associated with 1) trauma (OR 5.4, 95% CI = 2.6 to 11.6), 2) obstetrical and gynecological syndromes (OR 5.6, 95% CI = 2.4 to 13.2), and 3) psychiatric symptoms and substance use (OR 7.3, 95% CI = 2.4 to 22.0). The sensitivities and positive predictive values of these risk factors individually (<27.1% and <25.0%, respectively) and in aggregate (56.3% and 20.9%, respectively) were low. These indicators predicted only 27 (56.3%) of recently abused women. Lifetime domestic violence was more likely in homeless women (OR 5.8, 95% CI = 2.2 to 15.0), although less likely in immigrants (OR 0.4, 95% CI = 0.3 to 0.7). CONCLUSIONS: Clinical presentations and demographic characteristics of women presenting to the ED may not be sensitive or predictive indicators of domestic abuse. In the absence of typical clinical or demographic findings, asking all women in the ED about domestic abuse remains a necessary priority.     

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.     

Violence Against Nurses in the Triage Area: A Mixed-Methods Study

IntroductionWorkplace violence is a serious occupational problem among nurses in emergency departments. The aim of this study was to better understand workplace violence experienced by triage nurses.MethodsA mixed-methods study was carried out with 27 Italian nurses involved in the triage area of an emergency department. Quantitative data were collected using the Violent Incident Form and qualitative data were obtained from 3 focus groups.ResultsNinety-six percent of triage nurses had suffered an episode of violence during the previous year. Participants reported that perpetrators of violence were primarily patients' relatives or friends (62%), usually male and in a lucid state of consciousness. The aggressor was a male patient in 31% of violent episodes. Male nurses reported only verbal abuse, unlike female nurses who suffered both physical and verbal episodes. Females received assistance from other staff during the aggression event more frequently than males, and females more frequently suffered from physical injury. Only physical and verbal aggressions were associated with physical injury. Four main themes emerged from the focus groups.DiscussionNurses reported that high exposure to workplace violence in triaging had significant consequences on their psychological well-being and on their behavior at work and at home. Violence, perceived as a personal and/or professional injury owing to insufficient organizational support, led professionals to experience feelings of resignation and to believe that abuse was an inevitable part of the job. Nevertheless, in our study, the precipitating factors were investigated, suggesting several possible solutions to limit this phenomenon.     

Prevalence of violence and its relation to caregivers' demographics and emotional reactions: an explorative study of caregivers working in group homes for persons with learning disabilities

The aim of the study was to investigate the prevalence of violence directed towards caregivers working in group homes for persons with learning disabilities, and to examine the relation between violent incidents and caregivers' demographics such as gender, age, years in service, years at the present workplace and education, as well as emotional reactions to violence expressed by the caregivers. A questionnaire was distributed to all caregivers, i.e. Registered Nurses, assistant nurses and nurse's aides, working in group homes for persons with learning disabilities. The results showed that 31% of the caregivers (n = 120) had been exposed to violence during the preceding year with physical violence being the most common type of violence. All categories of caregivers were exposed to violence and emotional reactions were common. Weak relations were found between reported exposure to violence and various demographics among caregivers, such as age and education. Daytime work was the only independent factor in a regression model predicting violence towards the caregivers. Feelings of powerlessness, insufficiency and anger were the most frequently reported emotional reactions elicited by violent situations.     

An observational study of associations between nurse behaviour and violence in psychiatric hospitals

A cyclical model of violence to psychiatric nurses is proposed in this paper and a partial test of the model is reported. The model suggests that stress induced by exposure to violence leads to impaired staff performance and adoption of behaviours which make the re-occurrence of violence more likely. We tested the proposal that certain staff behaviours (e.g. expressing verbal hostility) are associated with an increased risk of assault by observing nurse–patient interaction on 12 psychiatric wards ( n =103 nurses). The verbal and physical interaction of (1) assaulted staff, (2) staff on violent wards, and (3) staff in grades which experience high levels of assault, were compared with those of respective low risk groups. There was some evidence of an association between interaction patterns and violence. We conclude this paper by discussing the implications of the model for psychiatric nursing practice.     

Prevalence, seriousness and reporting of work-related violence in the Danish elderly care

A survey study (paper and pencil) among staff of elderly care institutions in 36 Danish municipalities (n = 9949) was conducted in 2005 with a response rate of 78%. The majority of the participants of the study were women (96%). The paper presents the prevalence, perpetrators, seriousness (self-rated seriousness, injuries, sick leave and type of violence) of work-related physical violence towards care workers in the Danish elderly care and the frequency of reporting the incidents to the safety organization. The findings show that every fourth caregiver was exposed to violence in 2005. Care personnel working in nursing homes and integrated institutions had the highest prevalence of violence (40%) and were also most often (10%) exposed to violence. Clients were most often (>90% of cases) the perpetrators. The most frequent types of violence were hitting (63%) and scratching/pinching (63%). Being held (32%) or kicked (27%) was also mentioned as frequent types of violence; use of weapon, throwing or hitting with a hard objects were more seldom. Nearly 1/3 of the exposed respondents rated at least one incident as very serious. There were significant associations between self-rated seriousness and type of violence, injuries and sick leave. The incidents were, in particular when perpetrators were clients, often rated as not serious. Only 22% of the victims of violence reported the violent incidents to the safety organizations. Reports of violent incidents were significantly associated with frequency of exposure, type of violence, physical injury, sick leave and perpetrators. The more frequent and most serious cases were reported most often and cases where the perpetrators were clients were reported less often than when perpetrators were others. It has been suggested that underreporting of violence occurs because it is time consuming, lacks supervisory support, because it won't make any difference, because it is part of the job, and also because there is a tendency to 'downplay' the violence in the elderly care. Suggestions for researches and policy makers are made.     

Review article: Workplace violence in the emergency department: A systematic review and meta analysis

Patient or visitor perpetrated workplace violence (WPV) has been reported to be a common occurrence within the ED. No universal definition of violence or recording of such events exists. In addition ED staff are often reluctant to report violent incidents. The true incidence of WPV is therefore unclear. This systematic review aimed to quantify WPV in EDs. The association of WPV to drug and alcohol exposure was explored. The databases MEDLINE, Embase, PsycInfo and the Cochrane Library were searched from their commencement to 10 March 2016. MeSH terms and text words for ED, violence and aggression were combined. A meta‐analysis was conducted on the primary outcome variable‐proportion of violent patients among total ED presentations. A secondary meta‐analysis used studies reporting on proportion of drug and alcohol affected patients occurring within the violent population. The search yielded a total of 8720 records. A total of 7235 were unique and underwent abstract screening. A total of 22 studies were deemed relevant according to inclusion and exclusion criteria. Retrospective study design predominated, analysing mainly security records and incident reports. The rates of violence from individual studies ranged from 1 incident to 172 incidents per 10 000 presentations. The pooled incidence suggests there are 36 violent patients for every 10 000 presentations to the ED (95% confidence interval 0.0030–0.0043). WPV in the ED was commonly reported. There is wide heterogeneity across the study methodology, definitions and rates. More standardised recording and reporting may inform preventive measures and highlight effective management strategies.     

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.