Violence against health care workers is a major issue in health care organisations and is estimated to affect 95% of workers, presenting an enormous risk for workers and employers. Current interventions generally aim at managing rather than preventing or minimising violent incidents. To create better-targeted interventions, it has been suggested to shift attention to the perpetrators of violence. The aim of this study was to identify and discuss the perceptions, held by Emergency Department nurses, about perpetrators of occupational violence and aggression.
Two focus groups were conducted with Emergency Department nurses at a major metropolitan hospital in Australia. In the focus groups, the nurses’ perceptions about perpetrators of violence against health care workers were identified and discussed. The results were analysed using descriptive analysis.
This study confirmed that violence is a major issue for Emergency Department nurses and has a considerable impact on them. Participants acknowledged that violence at work had become an intrinsic part of their job and they tend to focus on coping mechanisms. The nurses identified six overlapping groups of perpetrators and described their approach to dealing with these perpetrators. The results highlighted additional factors that impact on the occurrence and management of violence, such as the presence of security, wait times, and the triage system.
Based on the focus groups with Emergency Department nurses we conclude that violence at work is an everyday danger for Emergency Department nurses, who feel vulnerable and recognise that it is not within their power to solve this issue given the societal component. Our conclusion is that attention needs to shift from equipping workers with tools to manage violence to the perpetrator and the development of interventions to reduce violence from targeted perpetrator groups.
Citation: Spelten E, Thomas B, O’Meara P, van Vuuren J, McGillion A (2020) Violence against Emergency Department nurses; Can we identify the perpetrators? PLoS ONE 15(4): e0230793. https://doi.org/10.1371/journal.pone.0230793
Editor: Alvisa Palese, Universita degli Studi di Udine, ITALY
Received: November 24, 2019; Accepted: March 8, 2020; Published: April 2, 2020
Copyright: © 2020 Spelten et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: Focus group data are available via Figshare (https://doi.org/10.26181/5e2f5d7dbf3e8).
Funding: This study was funded by a La Trobe University grant, Research Focus Area Building Health Communities, 2000002232. The funders has no role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Competing interests: The authors have declared that no competing interests exist.
Violence against health care workers is a major issue in health care organisations and is estimated to affect 95% of workers, presenting an enormous risk for workers and employers . Violence has relevance in all workforce settings and has rural, metropolitan and international angles .
Violence has an impact at personal, organisational, and societal levels. On a personal level, violence at work has a major impact on the health and well-being of the worker. Violent incidents can result in injury and death, as well as increase the risk of Post-Traumatic Stress Injury (PTSI) for workers. Violence can profoundly disrupt workers’ lives and have serious financial implications such as lost income and increased health care costs [3–5]. For organisations, next to concerns for staff health and wellbeing, there is a huge economic imperative as the occurrence of violence results in lost days of work, work incapacity claims, loss of expertise, and increased costs in investment to enhance safe work environments [4, 5]. On a societal level, violence may result in poorer clinical care and it raises questions about our societal values and norms. Although there is societal outrage at every extreme violent incident against a health care worker, there does not seem to be a corresponding reduction in violent incidents. This raises the question whether violence against workers is becoming normalised and accepted as an everyday danger for the worker? [6, 7].
Whether it is being normalised or not, the importance of the problem is acknowledged through the many interventions that have been implemented. Some interventions take a strong stance against violence and its perpetrators, such as the ‘zero-tolerance’ approach to violence. In general, the focus of many interventions appears to be on managing violent incidents, rather than preventing or minimising them, as is evident in the almost universal training of health care workers in de-escalation techniques, possibly indicating a one-size fits all approach to managing violence . Yet, there is little evidence that this, or any other interventions, have a significant impact on reducing the number of violent incidents [2, 5, 8].
To design interventions that focus more on preventing and minimising violence, we need to better understand the issues associated with the phenomenon. It has been suggested that attention needs to shift to the perpetrators of violence against health care workers ; a better understanding of types of perpetrators may result in a more tailored approach to these perpetrators of violence.
In this study we focussed on violence against Emergency Department (ED) nurses practicing at a metropolitan hospital in Australia that has identified reducing violence as a major priority. EDs are different from standard health care settings in a number of ways, which may impact the variation in violence they experience, and the way they deal with it. EDs have a patient population that is more heterogeneous than a mental health ward or aged care facility; nursing staff are less likely to have a previous relationship with the patient, unlike a family physician or a dialysis nurse. Additionally, patients and associates present to ED with an element of already elevated stress .
Furthermore, in recent years, ED presentations across Australia have increased considerably [11, 12]. Patients present to ED more readily, often because they do not have access to a family physician, or because they feel they require more specialised care. The staffing and resourcing of EDs has not always been in line with the increase in presentations [13, 14].
The aim of this study was to identify and discuss the perceptions, held by ED nurses, about the perpetrators of occupational violence and aggression. Mapping the perceived characteristics of perpetrators will inform the development of tailored interventions to reduce the risk of serious harm to health care workers. Although we acknowledge that violence against health care workers is unlikely to be completely eradicated, the ultimate aim is to design and implement interventions focusing on the perpetrator that will reduce and minimise this violence and to contribute to a safer work environment.
In this study we addressed the following research questions:
- Do ED nurses distinguish between different categories of perpetrators?
- How do they respond to different perpetrators profiles?
Two focus groups were held, at the hospital, with nurses from the ED, in which the nurses’ perceptions of the perpetrators of violence against health care workers were identified and discussed. The participants were asked to identify possible categories of perpetrators, without needing to be exhaustive or discuss them in a particular order. The focus groups questions are described in Table 1, for this paper we focussed on questions 3 and 4.
Each focus group had a maximum of 10 participants and lasted a maximum of 90 minutes. They were audio recorded for transcription and analysis. Verbal consent was obtained and recorded at the start of the focus group. Using verbal consent procedures for focus groups has become standard practice as they are an acceptable and more efficient way to obtain consent.
The focus groups were moderated by authors ES, BT, JV and AM, two females and two males, all researchers on this project. No additional persons attended the focus groups.
The ED where this study took place assesses around 240 patients per day, or 80,000 annually– 16,000 of these arrive by ambulance. It is a Level 1 tertiary referral centre, served by a helipad and a high acuity clientele–almost half of all patients require hospital admission. It is located in the Northern tip of the Melbourne CBD, providing care both to the local community and to trauma patients across Victoria, along with another health organisation.
For the reporting of our results, we used the COREQ standard .
Ethical approval for the collection of data from the ED nurses and the recording of verbal consent, was granted by the hospital’s Ethics Committee under number QA2018132.
The hospital invited their ED nurses to participate in the focus groups. They were provided with a Participant Information Statement, which explained the purpose of the study and the role of the researchers. Participants were given the opportunity to ask questions and discuss the information with others if they wished and verbal consent was obtained and recorded at the start of each focus group. The researchers sent an executive summary of results to their contact person at ED for distribution among staff.
The audio recordings of the focus groups were transcribed verbatim and analysed using thematic analysis . Verbal consent was transcribed separately and was not included in the transcript used for analysis. We used a phenomenological approach  and because of the exploratory nature of the study, inductive analysis was used as it allows for categories of perpetrators to emerge from the data without the analyst searching for specific answers . The data were coded by ES, BT, JV, AM using NVivo software .
The focus groups comprised 18 participants; the first group had ten participants and the second eight. No participants dropped out of the focus groups. There was a gender imbalance in the group with only two male participants, which is reflective of the nursing workforce in this setting . All participants worked in the ED as registered nurses. Their experienced ranged from 0–5 years to more than 15 years, with the majority having worked less than 10 years in ED (11). Most of the participants fell in the age bracket of 30–39 years (8), and the ages of the participants ranged from 18 to 59 years.
Categories of perpetrators
With thematic analysis, six distinct but overlapping categories of perpetrators were identified which are summarised in Table 2. Within each category, several groups of perpetrators could be identified. Table 2 summarised how the nurses would approach each type of violence. Both are discussed in more detail below.
Category 1: Violence that is not related to a health issue.
This diverse set of perpetrators refer to people whose violence or aggressive behaviour could not be explained by an underlying health issue. They could be patients but more often were bystanders or family members who were repeatedly referred to as persistent sources of violence. The participants suggested that family members could become violent if they feel frustrated, stressful, helpless, or entitled. ‘Copycats’ were next identified in this category, these are patients or bystanders who are under the impression that other visitors to ED ‘got away’ with having an aggressive attitude and might have received preferential treatment—they then tried the same behaviour. Next were patients unfamiliar with our health care system, travellers from overseas, or patients with a different ethnic background with a lack of English language skills or understanding of the ED system. This can lead to frustration and irritation, leading to aggression and violence. Lastly, in general, young adults were identified as a separate group with young men being aggressive/threatening and young women being ‘mouthy’ or verbally aggressive.
Category 2: Violence related to underlying mental health issues.
Patients with mental health issues were identified as an important category of perpetrators. One of the problems is the long wait time for mental health assessments, which leaves ED nurses to manage these patients. Participants mentioned that mental health issues ranged greatly in severity and complexity and that the situation becomes more complicated when mental health issues are used as an excuse for aggressive behaviour. The complex nature of mental health presentations could have an impact on the willingness of nurses to call for help or report incidents because they did not want to aggravate the patient’s situation.
Category 3: Violence related to underlying physical health issues.
An important category of perpetrators identified were patients who became violent because of an underlying medical condition, such as delirium, sepsis or hypoxia. The participants noted that the challenge is to determine that there is a physical health issue, and not assume it is a mental health or cognitive issue, and then identify the right issue and course of action.
Category 4: Violence related to substance abuse and addiction.
Unsurprisingly, the ED nurses identified concerned patients or non-patients, whose violent behaviour was related to substance abuse and addiction. In this category, smokers were singled out; it was noted that their behaviour (mostly smoking where it is not allowed) and attitude (not willing to stop or move) was often so aggressive in nature that the participants considered them to a separate group of perpetrators. A recent real-life example of violence related to smoking occurred in another Organisation similar to the one where this study took place with devastating consequences.
In this category, several groups of substance abusers were identified. Alcohol was perceived to be a bigger problem than any other form of substance abuse in relation to violent behaviour. Illegal substance users were seen as a group more prone to violent behaviour; ICE users were described as ‘hard work’—some participants commented on how relatively ‘easy’ in hindsight heroin addicts were in the past.
Category 5: Violence related to a complexity of issues.
A large group of patients whose aggressive behaviour is related to complex issues often involving, but not limited, to mental health issues were identified. These patients, presenting with more aggravated mental health disorders, were perceived as more complex and include patients with a personality disorder, or ‘antisocial’ personality, or patients with a psychosis. Equally, aggressive patients with dementia were challenging to deal with, as they do not ‘hold back’. Another identified group were patients with an intellectual disability or acquired brain injury that have persistent behavioural challenges as a result of their condition. The participants mentioned that patients with Asperger’s or Autism were a daily occurrence in ED. Nurses felt they were not adequately trained to deal with these patients. Some perpetrators had very complex issues, such as an aggressive patient with mental health issues, acquired brain injury, and substance abuse—they were perceived as very challenging.
Category 6: Violence that is related to repeat visitors/offenders.
Repeat presenters/perpetrators were the final category that was identified. These were patients who visit ED frequently and were known to have been aggressive or violent during previous visits. The participants often know these patients well which, in equal measures, can be a benefit and a hindrance.
Approach to violence and aggression
The discussion extended into approaches to violence and aggression, the second research question. Different perpetrators were approached differently, varying from the gentler ‘sleep and sandwich’ to the less gentle ‘shackle and sedation’. The range of management approaches that were mentioned in relation to the different categories of perpetrators, are summarised in Table 2.
Nurses in ED were, first and foremost, guided by their duty of care when dealing with violence at work. Nurses were proud of the fact that their hospital does not ban patients–in fact, most participants felt they had a high threshold to violence and aggression due to its frequent occurrence—they had a ‘massive tolerance’. At the same time, they were very mindful of patient’s stresses and would often see that as an excuse or a reason for their poor behaviour.
One of the reasons why participants said it was important that they were able to identify different groups of perpetrators is that their assessment of a type of perpetrator would inform their approach to handling the situation. The intent of the perpetrator is considered important and nurses assumed that the speed and ease with which a violent situation could be controlled is very much dependant on their effective assessment of the potential source of the violence and their capability to deal with it.
The following additional issues were identified in relation to violence:
- The importance of, and reliance on, security, in many different situations.
- Despite the high tolerance for violence, participants did mention feeling vulnerable. They feared retaliation and would ask security to escort them to their car or to the tram stop after work. Some participants said they would prefer to never encounter certain patients again because of the way they had behaved. Within this context, they can struggle with the unavoidability of contact with the same patient if they are a repeat presenter.
- The process of triage within the department was acknowledged to cause a bottleneck and could create a metaphorical barrier between the patient and the care provider. This could put considerable pressure on the person in this role and could add to the build-up of tension.
- The participants identified several organisational/societal factors that they thought contributed to the incidence and nature of violent incidents:
- ○ Waiting times are seen as a source of frustration and irritation.
- ○ Cultural barriers, particularly in relation to a predominantly female workforce, could lead to aggression.
- ○ The sicker the patient, the less aggression or violence you will see.
- ○ Young and less experienced staff could be, or feel, challenged more by aggressive patients.
- ○ Doctors were seen as a potential barrier to effectively deal with aggression—participants felt that doctors were less exposed to violence and could be more forgiving. This could be perceived as being unsupportive to the frontline nurse.
- ○ Social media, the instant posting and the public ‘naming and shaming’ was considered a major issue in relation to violence and made the nurses feel very vulnerable.
This study of ED nurses in a metropolitan hospital confirmed that violence is a major issue for them and it has a considerable personal impact. All participants acknowledged that violence at work had become an intrinsic part of their job and they tend to focus on coping mechanisms. The focus is more on managing and less on preventing violence. It became evident in the conversations that violence at work has a profound impact on the participants; their recall of incidents was vivid and it was clear that violent incidents had left a strong impression on them. The general sentiment was that nobody ever started a career in health care thinking this was going to be an everyday danger at their workplace. The participants acknowledged a recent culture change in their organisation and felt that the issue of aggression and violence was now addressed more seriously and to their satisfaction.
The nurses identified six overlapping groups of perpetrators and described their approach in dealing with these perpetrators. They suggested that their assessment of the type of perpetrator impacts on how they approach and deal with incidents. The results also highlighted additional factors that impact on the occurrence and management of violence, e.g. the presence of security, waiting times, and the triage system.
Interpretation of findings
The results of this study highlighted a number of issues around violence at work that are discussed below.
Different perpetrators–different approaches.
One of the aims of this study was to see if participants could identify different groups of perpetrators, our assumption being that there is no ‘one-size fits all’ solution to this problem. Apart from providing tools for management of violence, this approach could provide input into the much-needed prevention and minimisation of violence. Few studies have investigated nurses' subjective perceptions of workplace violence, with the majority of research in this area focussing on quantifying workplace violence . Nurses differentiating between different groups of perpetrators and varying their approach to different perpetrators has not been reported on in the qualitative literature [23, 24]. We found that the participants were readily able to distinguish between different categories of perpetrators and explain how their approach to perpetrators varied.
Nurses have learnt to accept violence as an inevitable aspect of their job. They acknowledge that there are bigger societal issues involved and it is not in their power to individually solve these issues.
The phenomenon of workplace violence has a major impact on the individual victims, the organisation and society in general, whether through economic costs, a weakening of societal trust, or a normalising of unacceptable behaviour. The extension to a societal level indicates that this is a problem that is not restricted to the hospital environment, which puts constraints on what the hospital and their staff can do to prevent and reduce violence. Society as a whole needs to own the problem if effective and acceptable solutions are to be found. The recognition of workplace violence as a societal issue is not new. Almost 25 years ago, the World Health Assembly declared violence as a major and growing public health problem . The focus of interventions for workplace violence in the ED is the education of staff and response to violent incidents, there is a lack of engagement from emergency departments to address workplace violence from a societal perspective [5, 8, 23].
Strengths and limitations of the study
We see the nurses’ willingness to talk and their frankness as a significant strength of this study. Equally, the support we received from the hospital management is testament to the organisation’s commitment to a safe workplace for their workers and to finding solutions to prevent and reduce workplace violence. Another strength of this study is that it gave voice to ED nursing staff who are the first to confront the problem within the hospital setting.
A limitation is that on the data is drawn from two focus groups with 18 ED nurses from one metropolitan hospital, which reduces the generalisability of the results. Other ED staff, such as doctors and security staff, will have different perspectives that would provide valuable insights . Validation of the experiences of ED nurses and other ED staff might be gained from a comparative examination of the available documentation such as incident data known as Code Grey/Black incident documentation.
Based on the focus groups with ED nurses we can conclude that violence at work is an everyday danger for ED nurses, who feel vulnerable and recognise that it is not within their power to solve this issue, given the societal component. Nurses are able to identify distinct categories of perpetrators and as a result they vary their approach to violent patients or bystanders. Our conclusion is that attention needs to shift from equipping workers with tools to manage violence, to the perpetrator and the development of interventions to reduce violence from targeted perpetrator groups.
We thank the Royal Melbourne Hospital and their staff for participating in this study.
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