Violence in the accident and emergency department

The Laying on of Hands: Nursing Staff Talk about Physical Restraint

‘Care and Responsibility’, previously labelled ‘Control and Restraint’, is a nationally recognized approach to physical restraint. This study explores how 11 nursing staff, who work with people with learning disabilities and behaviour that challenges services, evaluate the method. Whilst there has been a considerable debate in the literature concerning physical restraint methods – and the discussion is often vociferous – there is no consensus about the appropriateness of different approaches. Peculiarly, the opinions of staff are at the periphery, or worse still, absent from the arena. In this qualitative project, this issue is addressed by using intensive, semi-structured interviews to probe the views of the participants. The interviewees discussed a range of topics and identified a number of main themes. This paper details one of these, teamwork, and explores three key elements associated with this category.

Use of a Violence Risk Assessment Tool in an Acute Care Hospital

This study examined the use and effectiveness of the Alert assessment form. The form is part of the Alert system, used by one large acute care hospital to identify patients with a propensity for violence. All reported incidents of patient violence from August 1, 2003, through December 31, 2004, were included in patient charts. One hundred seventeen violent patient charts were reviewed and compared with 161 non-violent patient charts, randomly chosen from the same time period. Overall use of the Alert assessment form for violent and non-violent patients was 75.7% and 35.4%, respectively. The assessment form was found to have moderate sensitivity (71%) and high specificity (94%). It is reasonably effective in identifying potentially violent or aggressive patients when it is used according to protocol. Efforts to improve the tool are warranted, as is evaluation of its benefit in settings with low prevalence of violence. Also, greater effort must be taken to prevent violence once an aggressive patient has been identified.

Violence toward Health Care Workers

The aim of this study was to establish data for career prevalence and 1 year incidence of workplace violence for major categories of health care workers. Three consecutive work environment questionnaire studies at a large Swedish hospital provided the basis for the study. Prevalence and incidence rates of violence were age and gender adjusted to the Swedish working population. Prevalence of violence in the study population was compared to data from a national sample of Swedish registered nurses. Incidence of violence in each professional group was compared to that of the largest group of hospital employees, registered nurses. Standardized prevalence ratios for violence were significantly higher for all nursing personnel and physicians, and were highest for practical nurses (1.56). Standardized incidence rates ranged from 18/100 person years for physicians to 31/100 person years for practical nurses. The relative risk for violence at work over a 1 year period was significantly higher only for practical nurses (1.59) as compared to registered nurses. Nursing personnel and physicians were at considerable risk for workplace violence in the course of their careers. One year incidence rates were highest for practical nurses.

Physical Violence in the Workplace Among Jordanian Hospital Nurses

Purpose: Lack of policies and assertive legislations on workplace violence has placed Jordanian nurses at frequent risk for workplace violence. The purposes of this research were to (a) investigate the level of physical violence and the complaints and responses of Jordanian hospital nurses to such violence and (b) describe workplace policies that deal with violence and recommend policy directions. Design: A descriptive exploratory survey was used to investigate physical workplace violence among a convenience sample of 420 Jordanian nurses. Data were collected by a self-administered questionnaire that was developed in 2003 by the International Labour Organization, International Council of Nurses, World Health Organization, and Public Services International. Results: The findings indicated that 22.5% of the participants were exposed to physical workplace violence. The contributing factors as indicated by the participants were related to the administration, staff, security, patients and families, and the public. Discussion/Conclusion: Participants who had experienced workplace violence were very dissatisfied with the manner in which the incidents were handled. Implications: It is important to investigate consequences of workplace violence on the satisfaction of employees and the quality of heath care service. Instituting appropriate policies and legislations would minimize workplace violence.

Incidence and Related Factors of Violence in Emergency Departments—A Study of Nurses in Southern Taiwan

BACKGROUND/PURPOSE

Nurses in emergency departments are high-risk groups who are most likely to experience the offense of violent behaviors. In a comparison on the occurrence of verbal and physical abuses in emergency departments, this study aimed to analyze the correlation of staff properties and occupational conditions in an attempt to provide a reference on violence prevention.

METHODS

Eleven hospitals in southern Taiwan were selected and a survey of 267 nurses was conducted. The results were analyzed by percentage, Pearsons chi2 test and logistic regression.

RESULTS

The 236 valid questionnaires showed that nurses experienced significantly more verbal abuse (92%) than physical abuse (30%). The highest occurrence of verbal abuse was 49% in night shift, and the physical abuse was 44% in overnight shift. Long waiting (89%), difference in cognition (87%), and lack of communication (82%) were the common causes. The occurrences of verbal abuse and physical abuse were significantly correlated to less-informed (odds ratio [OR], 1.67 and 1.22, respectively) and basic-level nurses (OR, 2.30 and 1.34, respectively). In addition, younger age (OR, 2.80; p < 0.01) and single status (OR, 9.09; p <0.05) were correlated with occurrence of verbal abuse, but not of physical abuse. The test on occupational conditions showed a significant correlation (OR, 0.68/0.44; p < 0.005) between the occurrence of verbal/physical abuse and whether supervisors could provide enough training to cope with violence.

CONCLUSION

This study suggested that a well-informed nurse should be arranged to take the night/overnight shifts in order to reduce the occurrence of abuses in emergency departments.

Patients longing for authentic personal care: a phenomenological study of violent encounters in psychiatric settings

This article focuses on patients' violence against caregivers. Several studies show that violence and threats within the health care setting are an increasing problem. Encounters that become violent have been the issue of many debates but the phenomenon is still not fully understood. It is important to understand the course of events in violent encounters, both for the sake of the patients and the caregivers' well-being. The aim of this study was to describe the essence of violent encounters, as experienced by nine patients within psychiatric care. Guided by a phenomenological method, data were analyzed within a reflective life-world approach. The findings explicate violent encounters characterized by a tension between "authentic personal" and "detached impersonal" caring. "Authentic personal" patients are encountered in an undisguised, straightforward, and open way, and they sense unrestricted respect that caregivers would show another human being. In these encounters violence does not develop well. However, in caring that is "detached impersonal," the encounters are experienced by the patients as uncontrolled and insecure. These encounters are full of risks and potential violence.

Terminology, stereotypes and aggressive dynamics in the accident and emergency department

There is a perception that violence against staff practising in accident and emergency (A&E) departments is increasing [Fernandes, C.M.B., Bouthillette, F., Raboud, J.M., Bullock, L., Moore, C.F., Christenson, J.M., Grafstein, E., Rae, S., Ouellet, L., Gillrie, C., Way, M., 1999. Violence in the emergency department: a survey of health care workers, Canadian Medical Association Journal 11, 1-6; Jenkins, M.G., Rocke, L.G., McNicholl, B.P., Hughes, D.M., 1998. Violence and verbal abuse against staff in the A and E departments: a survey of consultants in the United Kingdom and Republic of Ireland, Journal of Accident and Emergency Medicine 15, 262-265; . A survey of violence towards nursing staff in one large Irish Accident and Emergency department, Journal of Emergency Nursing 23(3), 214-219]. This paper discusses traditional stereotypes of the violent A&E client by critiquing the current literature. The paper then goes on to question whether some health care professionals themselves are contributing to a climate of fear and the development of conflict.

Personal safety in the accident and emergency department

Violence and aggression continues to be a significant problem for staff practising in accident and emergency (A&E) areas. In recent years the number of articles examining factors related to violence and aggression in the A&E department have steadily increased, allowing for a more in-depth examination of data. This article considers the characteristics of individuals who assault A&E staff, introducing the reader to the "recreational fighter", an individual who enjoys and is attracted to violent confrontations. The article goes on to consider the role of gender, alcohol, age and social history in relation to the characteristics of individuals who assault nursing staff practising in A&E and offers a number of strategies for nursing staff to consider when attempting to minimize the risk of personal physical assault.

Violence in the accident and emergency department – An international perspective

Violence and aggression experienced by emergency nurses has been the focus of international concern. This paper examines the phenomena of violence experienced by emergency department nursing staff from an international perspective by reviewing original, published research studies. Methodological inconsistencies and concerns, a lack of comprehensive studies and persistent under-reporting may mean that the reality of clinical practise has not being captured by researchers. The literature suggests that clients presenting with weapons in the emergency department may be characteristic of North American departments but is much less likely to occur in the United Kingdom were weapons use is much more likely to be opportunistic. Excessive verbal abuse is a global phenomenon and nursing staff and organisations may be significantly affected by workplace violence. However, violence against nursing staff remains poorly researched or understood.

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.

A balanced approach to dealing with violence and aggression at work

The Government has introduced tough measures in dealing with violence and aggression in the workplace. Employers have a duty to provide adequate safety measures and training to reduce risks and ensure, where possible, the health, safety and welfare of their employees. This article highlights the responsibilities of employers and the pressures in both hospital and community environments on staff at risk from violent or abusive incidents. The patient's perspective is discussed, suggesting that more understanding between patients and staff is needed. The article looks at the "NHS Zero Tolerance Zone Campaign" and whether this can be enhanced by introducing training of an empathetic nature along with other practical environmental issues. It suggests that there are alternative and more effective, techniques in dealing with violence and aggression that can be used to defuse a situation before it ever becomes a physical altercation. The philosophies of eastern martial arts can teach us a lot about personal self-esteem and confidence which are two key elements in managing conflict situations.

Aggressive and violent incidents: perceptions of training and support among staff caring for older people and people with head injury

BACKGROUND

Reported rates of workplace violence are increasing and studies of violence and aggression to health service staff in the United Kingdom have largely focused upon mental health and accident and emergency units. The study of violence and aggression in other specialties has been neglected. This paper reports the findings from a survey of staff perceptions of training and support in an elderly care and head injury unit.

AIMS AND OBJECTIVES

Staff in a care of older people and head injury unit, half of whom were nurses, were surveyed to identify their experiences of violence and aggression in the workplace, their receipt of training, the relevance of training and knowledge of support services.

METHODS

An anonymous semi-structured questionnaire was sent to all nursing, therapy and psychology staff in the unit. Quantitative data were analysed by SPSS and content analysis was adopted for the qualitative data.

RESULTS

Just over half the participants had experienced an incident of violence or aggression in the past 12 months. Training was judged to be relevant by almost 90% of respondents but was not always delivered in line with trust guidance. Staff who had been involved in incidents were more likely to identify training needs. A higher percentage of nurses than other professions were involved in incidents, but they were not as aware of the staff support department as other professional groups.

CONCLUSIONS

The findings indicate that care of older people and head injury units should examine more closely the delivery of staff training on violence and aggression, and invite staff to identify their training needs. A national survey of approaches to staff support may be worthwhile.

RELEVANCE TO CLINICAL PRACTICE

Staff who had received training judged it to be relevant to their working situations, but outstanding training needs should be identified and addressed. Confidential staff support facilities should be well publicized.

Violent encounters in psychiatric care: a phenomenological study of embodied caring knowledge

This article focuses on encounters that become violent, a problem in health care that has been the issue of many debates but is still not fully understood. Violent encounters refer to events where the patient expresses an aggressive and hostile attitude toward the caregiver. This study is part of a bigger project that aims to elucidate violent encounters from the caregivers' as well as the patients' perspectives. The purpose of this particular study was to describe the essence of violent encounters from the caregivers' perspective. Guided by a phenomenological method, data were analyzed within a reflective lifeworld approach. The essence of a violent encounter between caregivers and patients, as experienced by the caregivers, is a critical moment characterized by a tension between presence and distance, a moment where everything is happening at the same time. There are important meaning differences in relation to the violent encounter being viewed as positive rather than negative, based on the caregivers' ability to be present and their capacity in these trying situations to manage their fear. The findings also make explicit the particular knowledge that is needed for the caregiver to manage the threat of violence in a creative way.

Recognizing and managing violence in the NICU

PURPOSE

To determine (1) the nature and frequency of threatening or violent events in the NICU workplace, (2) whether nurses feel confident in their ability to recognize and deal with these events, (3) whether there is an association between violence training and confidence in the ability to recognize and manage violence, and (4) whether NICU nurses report and document these events.

DESIGN

A descriptive, self administered questionnaire.

SAMPLE

A nonprobability sample comprised of 68 RNs employed in a Level III NICU in a midwestern metropolitan-area hospital.

MAIN OUTCOME VARIABLES

Types and frequencies of threatening or violent events in the NICU; nurses' confidence in their ability to recognize/manage these events; nurses' reporting/documentation of these events.

RESULTS

Fifty-four percent of the sample experienced threatening or violent workplace events; 83.8 percent of the sample felt confident in their ability to recognize violent situations; 69.1 percent felt confident in their ability to manage violent situations. Various means were reported for documenting and reporting such events, but 27 percent neither reported nor documented violent events.

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.

The lived experience of violence in accident and emergency

AIM

To investigate the lived experience of violence of nurses in one A&E department.

RATIONALE

Following an extensive literature review, it was elicited that there was very little evidence of the psychological impact of violence in A&E.

BACKGROUND/INTRODUCTION

Violence in the health service has increased over the last decade associated with a corresponding increase in the published literature on this topic. While violence in A&E departments would appear common, little evidence exists on the psychosocial impact of these incidents on A&E nurses.

RESEARCH METHODS

A qualitative domain using a phenomenological philosophy was utilised. Sampling was of a volunteer nature and data were collected using interview. Nurses were sampled from one major acute hospital in Northern Ireland.

RESULTS

Participants expressed feelings of frustration, anger, and fear. Support from colleagues was greatly valued and lack of feedback from management was cited as being common.

DISCUSSION

Frustration and anger were synthesised into the "why me" principle with nurses not knowing why they were the focus for attack. Violent incidents were associated with a sense of isolation but colleague support developed a sense of belonging.

CONCLUSIONS

Whilst a useful insight was provided, more research is essential into this emotive topic.

How prevalent is violence towards nurses working in general hospitals in the UK?

BACKGROUND

Violence in nursing is not a new phenomenon but in recent years much greater emphasis has been placed on the problem in the United Kingdom (UK). A number of official reports, media stories and national initiatives have focused attention on the problem in this country. However, it is not clear whether violence and abuse have in fact become more prevalent. At present little is known about the scale of the problem for general nurses working in general hospitals in the UK.

AIM OF THE STUDY

A realistic assessment of the scale of this problem should facilitate a meaningful debate about the interventions needed to counter it and support the requests for funding that will be required. This study aimed to establish the utility of existing research findings, to include relevant but previously unused sources and to synthesize the results.

METHOD

A systematic search of the literature pertinent to the aim of the study was followed by a critical review. The focus was on research originating in the UK, including some general research on occupational violence which included data on nurses.

FINDINGS

Overall, the research findings are limited. The best available evidence suggests nurses as a whole do face a high level of risk compared with all workers and this excess risk holds for general nurses. The data support a figure of more than 9.5% of general nurses working in general hospitals assaulted (with or without injury) in any 1 year. Trends over time are impossible to identify at present.

CONCLUSIONS

Efforts to combat the problem should include greater emphasis on the problem outside accident and emergency departments, prioritizing preregistration training in the management of aggression, and further research. Better reporting should also be a priority.

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.

Violence in A&E departments: a systematic review of the literature

Violence against A&E staff is increasing, and national initiatives have been implemented to counter the threat to staff. The aim of this paper is to determine the risks to staff of working in A&E and to determine methods of risk-reduction, using searches of literature and web-based resources. There is also critical appraisal of the data therein.

Nurses' perceptions of the nature and frequency of aggression in general ward settings and high dependency areas

Studies on aggression in healthcare settings have reported increased frequency of this behaviour in both psychiatric and accident and emergency areas; however, to date, very few studies have addressed this issue in general ward settings in Australia. This descriptive study was conducted to determine nurses' perceptions of the nature and frequency of aggressive behaviours in general wards and high dependency areas and thereby address the gap in the literature. Two hundred and nine nurses in one Australian hospital completed a 23-item questionnaire on aggression in the workplace. The findings revealed that the majority (89.5%) of nurses defined aggressive behaviour as including verbal aggression, physical aggression and intimidation. Ninety-five per cent of respondents had encountered at least several episodes of verbal aggression within the last 12 months. Patients were found to be the main perpetrators of aggressive acts, followed by relatives. After experiencing either verbal or physical aggression nurses most frequently reported feeling angry or emotionally hurt. These findings confirm that acts of aggression are experienced frequently in the general medical and surgical ward areas of the study hospital. Consequently, there is a need to provide staff with education and support in order to deal with this issue and minimize the impact of increasing levels of aggression in the workplace.

Violence and aggression in A & E: recommendations for action

The problem of violence and aggression in health care settings has become a high-profile issue. Following the release of figures issued by the Health Services Advisory Committee (HSAC) which show nursing as the most dangerous profession in the UK, Frank Dobson, Health Secretary, urges health service managers to do everything they can to reduce violence. Violence is defined as any incident which puts a health care worker at risk and includes verbal abuse, threatening behaviour or assault by a patient or member of the public. It is suggested that most violent incidents within the hospital setting contain an intentional and, therefore, aggressive element. The theoretical background to the concept of aggression is explored to pinpoint its causes and identify the factors which originate its potential for harm. An analysis of the Accident and Emergency (A & E) environment with the conflicting demands of its workload highlights its potency for the creation of violent and aggressive behaviour towards its staff. In order to minimize its detrimental effects, this paper examines various approaches towards counteracting violence and aggression. It concludes that these methods fall into five major categories and details recommendations for action within these areas. The HSAC (1997) declares that it is possible to reduce the risk of violence by proactive management, underpinned by positive commitment from senior managers and staff at all levels.

Violence and verbal abuse against staff in accident and emergency departments: a survey of consultants in the UK and the Republic of Ireland

OBJECTIVES

To determine the incidence of verbal abuse and physical violence in accident and emergency (A&E) departments and to discover the extent of provision of security measures and instructions for staff on how to deal with these problems.

DESIGN

A postal questionnaire.

SETTING

A&E departments in the UK and the Republic of Ireland.

SUBJECTS

Two hundred and seventy three consultants named in charge of 310 departments.

MAIN OUTCOME MEASURES

Frequency of physical violence and verbal abuse, injuries sustained, perceived precipitating factors, security measures instituted, and legal action taken.

RESULTS

Two hundred and thirty three replies were received. Alcohol, waiting times, recreational drug usage, and patients' expectations were perceived as the chief causes. Patients were the chief perpetrators with nurses being the commonest victims. Staff sustained 10 fractures, 42 lacerations, and 505 soft tissue injuries. There were 298 arrests and 101 court appearances that resulted in 76 convictions. Panic buttons and video cameras were the most common security measures.

CONCLUSIONS

Staff within A&E departments are regularly abused, both verbally and physically. Inner city departments appear to be most affected. Documentation is poor. Perpetrators are seldom convicted. There do appear to be actions which hospitals could undertake that might help to ameliorate these problems.