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Nursing and Health Sciences (2015), 17, 307–312
Research Article
Nursing management of aggression in a Singapore emergency department: A qualitative study Mei Fen Tan, BSc (Nursing) (Hons),1 Violeta Lopez, RN, PhD2 and Michelle Cleary, RN, PhD3 1 Neuroscience Intensive Care, Tan Tock Seng Hospital, 2Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore and 3School of Nursing and Midwifery, University of Western Sydney, Sydney, New South Wales, Australia
Abstract
In Singapore, anecdotal evidence suggests that nurses are concerned about managing aggressive incidents in the emergency department. In this study, registered nurses’ perceptions of managing aggressive patients in an emergency department were explored. Ten registered nurses from the emergency department of an acute public hospital in Singapore were interviewed. Four overarching themes emerged from the thematic analysis: (i) impact of aggressive patients on nurses; (ii) nursing assessment of aggressive behaviors; (iii) nursing management of aggressive behaviors; and (iv) organizational support and responsiveness. Further research is required to better support nurses to deliver optimal care for aggressive patients and achieve positive and effective outcomes.
Key words
aggression, education, emergency department, management, nurse, Singapore.
INTRODUCTION Workplace aggression refers to “incidents where employees are abused, threatened or assaulted or subjected to other offensive behavior in circumstances related to their work” (Martino, 2003, p. 5). Aggression in the healthcare sector has been a concern for many years, especially among the nursing profession. Globally, one-third of the nursing population experience some form of workplace aggression in any 12 month period, two-thirds of nurses experience nonphysical violence, and one-quarter experience sexual harassment (Spector et al., 2014). The emergency department (ED) is noted as a high-risk area for workplace aggression. For example, in Australia, emergency nurses reported 110 episodes of violence within a 5 month period, with 37% occurring on the evening shift (Crilly et al., 2004). Research shows, ED nurses experienced physical injuries resulting in psychological effects, such as anger, burnout, stress, anxiety, and fear (Gillespie & Melby, 2003; Needham et al., 2005). Nurses were concerned about their perceived inability to predict patients’ behaviors and future violent incidents (Canbaz et al., 2008). A review of the literature found that a sense of apathy by nurses or their managers has contributed to the underreporting of workplace aggression (Pinar & Ucmak, 2010; Wolf et al., 2014). Deficits in administrative and policy-based practices are also noted (Choiniere et al., 2010; Pich et al.,
Correspondence address: Michelle Cleary, School of Nursing and Midwifery, University of Western Sydney, Locked Bag 1797, Penrith, NSW 2751, Australia. Email: [email protected] Received 10 July 2014; revision received 13 October 2014; accepted 31 October 2014
© 2015 Wiley Publishing Asia Pty Ltd.
2010); for example, ED nurses in Taiwan report that restricting visitors’ access to ED leads to physical aggression (Tang et al., 2007).While aggression-management training is recommended for nurses, evidence suggests that the implementation of a one-time aggression training program is inadequate, and that the content could be more practical (Delaney et al., 2001; Pich et al., 2010). In Singapore, the nursing profession is predominantly female, there is a shortage of registered nurses (RN), and the nursing workforce has a strong work ethic, typically working long hours to meet tight deadlines (Cleary et al., 2013a,b). According to Gantz et al., (2012), Singapore has a younger nursing workforce than in most developed countries, and there is substantial attrition of nurses within the first three years of their career related to the less-than-ideal working environment. Anecdotal evidence suggests there is an absence of policy in support of an aggression-free workplace (zero-tolerance legislation, prevention strategies, and mandatory training in aggression management), which differs to many Western nations (Pich et al., 2010). There is also a paucity of research in relation to patientrelated aggression toward nurses, especially in ED. Research by Chan et al. (2013) found that patient and/or relative aggression is the most common type of work-related aggression experienced by healthcare workers. A peer-help, multicomponent crisis response-management system has been made available by the Ministry of Health to Singapore public general hospitals since 2008, but a multisite healthcare workers survey by Chan and Chan (2012) revealed that only 10.6% of nurses have used the system to seek emotional support for work-related aggression. To date, there is only one research study that actually focused on aggression in doi: 10.1111/nhs.12188
308
Singapore (Yusuf et al., 2006); the restricted scope of the investigation (verbal aggression and psychiatric hospital) limits the applicability of the findings to other general hospitals. ED are a high-risk area for aggression, and abuse toward nurses is relatively common, accepted as part of the job, and embedded in the culture (Pich et al., 2010). Current evidence points to the need to further explore nurses’ perspectives of how best to care for people exhibiting aggressive behaviors, which could contribute to efforts in reducing the adverse effect on nurses and identify the impediments for the required changes by organizations or individual healthcare professionals (Cohen et al., 2013; Hahn et al., 2012; Needham et al., 2005; Pich et al., 2010). It is against this background that the present Singaporean study was developed. In this study, ED nurses’ perceptions of managing aggressive patients were explored. Although there have been a number of studies that have focused on the impact of patients’ aggressive behaviors in nurses, this qualitative study is the first in Singapore to explore nurses’ perceptions of managing aggressive patients presenting to the ED.
METHODS The setting for this study was a 24 h ED at a major Singapore general acute hospital, with separate ED facilities for adult and pediatric patients. The inclusion criteria were RN who had prior contact with aggressive patients and had worked in the adult ED setting less than three months. For the protection of human participants, approval for this study was obtained from the National Healthcare Group Domain Specific Review Board. Advertisement flyers and a staff briefing were used to recruit potential participants. Interviews were arranged at a mutually-agreed venue and time, and all participants provided written consent after they all understood the nature and purpose of the study. The interview guide was adapted from a previous study (Delaney et al., 2001), with permission granted before being piloted with two colleagues. Interview topics included demographics, assessment of aggression, nursing interventions, communication skills, education and training, de-escalation and physical restraint skills, post-aggressive incident support and follow up, and other issues or relevant factors. The interviews were conducted in English and all were digitally recorded, with each lasting between 30 and 60 minutes. The principle of data saturation was adopted to establish sample size; that is, until interview content became repetitive and unlikely to generate new information from further data collection (Morse & Field, 1996). Data collection and analysis proceeded simultaneously (Coffey & Atkinson, 1996). Verbatim transcriptions of the data were analyzed according to the tenets of thematic analysis and included becoming familiar with the data, generating initial codes, searching for and reviewing themes, defining and naming themes, and producing the report (Braun & Clarke, 2006). These steps provided a systematic process for the researcher to conduct the thematic analysis and develop themes from the interview data. © 2015 Wiley Publishing Asia Pty Ltd.
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RESULTS Ten RN aged 22–30 years were interviewed, and eight (80%) were female. The participants had spent their entire nursing career in the ED, and had 2–8 years of working experience. Three (30%) participants were diploma holders, four (40%) had an advanced diploma, and three (30%) had attained a bachelor degree as their highest nursing qualifications at the point of data collection. The thematic analysis yielded four themes: (i) impact of aggressive patients on nurses; (ii) nursing assessment of aggressive behaviors; (iii) nursing management of aggressive behaviors; and (iv) organizational support and responsiveness.
Impact of patients’ aggressive behaviors on nurses ED nurses reported that caring for aggressive people affected them psychologically and physically. The psychological effects included feeling upset, not feeling appreciated, and having recurrent thoughts about what could be done better. The frequent exposure to aggression created job dissatisfaction, resentment, and regrets about initiating the interaction with the person. Some of the nurses also reported feeling burned out and wearisome about continuing with their work duties: I was punched . . . it was quite painful. So I kept thinking what can I do better? Why must I go and attend to that patient? Sometimes I feel like I should just ignore that person. (Participant 3) Fracture was also reported as a consequence of aggression, and the majority of nurses were not always able to prevent aggressive incidents. As a result of the physical injuries sustained, nurses were not always able to complete their nursing duties and were required to take sick leave.
Nursing assessment of aggressive behaviors An integral part of managing aggression is the ability of nurses to employ various nursing-assessment strategies. In this study, nurses during their clinical encounter with aggressive people used presenting information and previous history, as well as nurses’ reflection on past experiences to assess the person. They also relied on the medical diagnoses (i.e. alcohol intoxication, delirium) to determine the possibility for aggressive behavior. All interviewees indicated that alcohol intoxication contributed to a higher likelihood of aggressive behaviors. Nurses also attributed possible underlying medical conditions, such as sepsis, electrolyte imbalances, heat stroke, dementia, and seizures, to aggressive behavior. Several nurses also reported that if they receive information on a patient admitted with a drug overdose or a risk of self-injury during the handover of care, they would consider these patients to be potentially aggressive. Nurses also used their observation skills as part of the routine assessment for potentially-aggressive people. Specifically, nurses observed body language, verbal cues, and signs of unhappiness or dissatisfaction via the content, tone, and volume of the patient’s speech:
Nursing management of aggression
You can observe their behavior is a bit abnormal when a patient starts to shout and (they) don’t obey your commands. Potentially, they will be difficult to manage. (Participant 10)
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also resorted to seeking help from the security department when they were unable to satisfactorily manage the aggressive situation:
The nurses were quick to determine that those with the aforementioned presentations would have some form of risk for aggression in addition to being regular users of the ED:
We (nurses] call the security to come . . . You can’t possibly sedate an alcohol-intoxicated patient because . . . they will get more sedated . . . you can’t physically restraint them too, because they are . . . (still) conscious and they are quite strong. (Participant 8)
I already know that this patient tends to be aggressive, because they already have a history, or I have already seen them being aggressive . . . we have regular patients, drunk patients, who regularly turn up in our department. (Participant 9)
Nurses reported contacting the police if it was perceived to be a case of severe physical aggression or when the person threatened the nurse. Nurses urged for changes so that they were more supported:
The nurses reported making quick judgements to categorize patients, as the use of chemical or physical restraints might be necessary to effectively manage aggressive incidents.
Nursing management of aggressive behaviors Despite sustaining injuries, nurses spoke about their professional obligations and the importance of upholding standards and good service. These nurses also reported making extra efforts to interact with aggressive people, even when they were reluctant to do so: You need to . . . be nice to them, but not too nice (to the extent) you do everything for them . . . just be nice to them, do whatever you need to do. (Participant 1) Caring for aggressive people was deemed to be time intensive. As a result, the majority of nurses believed that they could not do what they should do for all persons in their care. Across all the interviews, nurses adopted a stoic stance on the issue of aggression, and viewed dealing with aggressive incidents to be part of their job. Nurses perceived that they could manage the challenges of caring for aggressive people, despite the potential for physical or psychological injury: I’m not affected that much, because I think it (aggression) is normal inside ED, and people come in with these kinds of conditions. (Participant 2) However, some nurses reported instances where they or their colleagues were unable to maintain professionalism:
I called (the police) to come and help me because it is a very violent patient in the department. So after taking down my report . . . they asked me, “Do I want to pursue the matter?” . . . I was thinking . . . why am I given a choice to pursue this matter? Can’t they choose to pursue them instead of me charging him for doing all these violence and vulgarities? Because if I pursue this matter, they told me, it is under civil law and I sue him accordingly. (Participant 7) It was also noteworthy that other than managing aggressive incidents, nurses also needed strategies to be able to let go of negative emotions. Many nurses explained that their coping strategies had helped, and examples they gave included venting to colleagues and family, separating professional duties from one’s personal life, and engaging in regular leisure activities.
Organizational support and responsiveness According to the ED nurses, debriefing sessions conducted after incidents were infrequent, and sometimes there were none at all. For incidents that were perceived as inconsequential, nurses reported that the nurse managers did not show concern or render support. Inconsequential incidents appeared to be justified and normalized by the high frequency of aggressive incidents. Most of the nurses sought support from colleagues – “counseling each other” – to cope with the emotional effects. They expected front-line leaders, such as senior nurses, to have the competency to manage aggressive incidents and to be their role models:
Of course, at the scene, we are very angry . . . We . . . shout at the patient: “Hey you don’t – you must obey us”. (Participant 3)
I need the help of my senior nurses to teach me . . . how to properly manage (aggressive patients) or how to decide what interventions to use (in aggression management). (Participant 4)
Nurses had proactively offered to take over the responsibility for care in the few instances in which they observed their colleagues being unable to maintain their professionalism toward patients. Frequent interaction with patients was deemed important to prevent aggression, including providing information and updates. This included using hospital translators if language was deemed a communication barrier. Chemical and physical restraints were used to manage aggression to ensure safety and allow the healthcare staff to carry out important investigations and treatments. Nurses
Besides senior nurses, male nurses tend to step forth to assist in aggressive incidents. Not all nurses reported being familiar with the available guidelines, policies, and procedures that could help them manage aggressive incidents. It was suggested that the guidelines should provide a systematic form of assessment to identify people who can potentially turn aggressive. However, current guidelines, protocols, and policies provided directions on when to call the police and seek help. It appears that most nurses filed police reports when they received verbal threats from their patients: © 2015 Wiley Publishing Asia Pty Ltd.
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One patient said: “You don’t let me see you outside the hospital. I’ll kill you if I see you”. So because of this case, we made a police report. Because it is (a) threat and you won’t know if he really will come back and kill you, because he can just wait outside for you in (this hospital), then . . . follow you home. (Participant 6) As part of the ED’s protocol, it was mandatory for nurses to write incident reports for incidents of physical aggression. Similar to incidents of verbal aggression, nurses reported that the decision to complete a report was at their discretion. Across all interviews, nurses believed that incident reports were important and necessary to avert legal liabilities in the event of alleged negligence or complaints against the nurse: Because the patient is threatening us . . . we really have to do write something in the incident report . . . if ever the patient sues us or writes a complaint letter, we have this written report of what really happened that time, that day. (Participant 5) Despite the importance of incident reporting, nurses found the process cumbersome. They also perceived that management rarely acted on reports or provided additional resources to support nurses in managing aggressive incidents. Workplace education, preparation, and training were deemed important to prepare nurses in ED for their role in managing aggressive behaviors. Some nurses stressed the importance of actual workplace experience in gaining skills, knowledge, and confidence: I think the experience gained from working here will help you . . . It is better than any course . . . there is no course that can teach you. It is just valuable experience. (Participant 6)
DISCUSSION ED nurses’ experiences of the impact of patients’ aggression, as well as their perceptions of managing aggressive patients, were explored in this study.The findings resonated with many other studies about the myriad of consequences ED nurses experience from aggressive encounters (Gillespie & Melby, 2003; Zampieron et al., 2010). Nurses in this study reported bodily injuries (e.g. being hit, kicked, and pushed), and verbalized reluctance in caring for aggressive people, although acknowledging their professional obligation to care for such people.The findings regarding these negative effects resonate with the literature, including feeling burned out (Gillespie & Melby, 2003; Lau et al., 2012; Lo et al., 2012; Chan et al., 2013; Kowalenko et al., 2013). The nurses were able to identify potentially-aggressive people when they factored the patient’s medical or nonmedical presentation into account. The findings of this study are supported by previous research. Alcohol intoxication, the use of drugs/drug overdose, as well as the presence of mental illness were cited by nurses as contributing to aggressive incidents (Crilly et al., 2004). Similarly, nurses cited medical conditions as biomedical cues to determine the aggression risk of patients. Health service-related reasons, such as long waiting times or patients seeking ED admission due to socio© 2015 Wiley Publishing Asia Pty Ltd.
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economic reasons, could also result in patients exhibiting aggressive behaviors. Previous research has reported similar findings, where nurses perceived that people who could not tolerate the long waiting times were potential aggressors (Wong et al., 2007; Wolf et al., 2014). This problem is also attributed to the current setting in this study, where waiting times to see a doctor could vary between 4 and 10 h. Strategies to decrease waiting times are currently being reviewed in this setting. In this study, nurses also depended on the recall of past experiences to identify potential aggressors. These were people whom they have had previous aggressive encounters with. Observation skills were particularly useful for nurses in this study in identifying behavioral cues for potential aggressors. It might be useful if ED nurses in Singapore consider formal assessment tools to guide their assessment for aggression risk, and this warrants further consideration. Nurses in this study perceived the care of aggressive people as part of their everyday work duties; this was justified by the common occurrence of aggression in their workplace. The challenge for ED nurses was maintaining their professionalism during an aggressive encounter. As part of their professional code, nurses are required to embody core values of care and empathy, although it might prove difficult to express naturally in non-ideal situations (Zapf, 2002; Spector et al., 2014), especially when dealing with people who might not be appreciative of the nurses’ efforts. Nurses urged for the development of resources in order to help them cope with the challenges in the workplace, and they valued security and police as aggression-management resources. Similar to previous studies, nurses reported that most of the security guards were quick in their arrival and assisted the nurses during aggressive incidents (Gillespie et al., 2012). However, more organizational efforts are needed in ensuring a reliable security workforce that can readily assist in aggressive incidents. As demonstrated in the findings, nurses acquired aggression-management skills by learning from other more experienced nurses when transitioning to the workplace as graduate nurses. The benefits of role modeling are noted in the literature (Omansky, 2010; Cleary et al., 2013). Nurses recommended aggression-management training programs to enhance their confidence, as well as the need to strengthen current induction programs. Most of the nurses mentioned the use of current guidelines, protocols, and policies in guiding their nursing care of aggressive patients in this study. However, they expressed a need for further organization support to enhance the available support and network system for staff who encounter or work with aggressive patients, including the provision of a formal debriefing system.
Study limitations As with all studies, there are a number of limitations for this research project. The project was conducted at a single site with a small group of ED nurses. Further, findings explored registered nurses’ experiences in one emergency department in Singapore, and therefore, are restricted in scope and transferability, especially in Western countries.
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Implications for nursing practice
REFERENCES
Consistent with international reports, workplace aggression appears to be relatively common in the ED and needs to be addressed to avert its physical and psychological effects on nurses, as well as other healthcare workers in the ED. In this study, nurses’ awareness of patients who might be potentially aggressive was mainly based on past experiences. However, there is a need for a more reliable and valid way of assessing these patients, and such a tool should be used as part of a routine assessment of all patients presenting in the ED. The study also highlights the need for more thorough education programs, not only to prepare nurses in handling aggression at the workplace, but also other work-related crises. Such programs must be well structured, evidence based, and multidisciplinary focused, and should be provided during the orientation of new healthcare workers and as needed. Management is also encouraged to provide a supportive environment for staff who experience aggressive behaviors, so as to encourage staff to report all incidents and be assured that they will be acted upon. The long waiting times of patients in the ED are a worldwide problem that contributes to aggression. All ED should explore the factors that contribute to the long waiting times and implement strategies to improve the flow of patients more effectively. The role of the multidisciplinary team, including security officers, must also be acknowledged and warrants further exploration and research.
Braun V, Clarke V. Research in nursing and health care: evidence for practice. Qual. Res. Psychol. 2006; 3: 77–101. Canbaz S, Dündar C, Dabak S, Sünter AT, Peks¸en Y, Cetinog˘lu EC. Violence towards workers in hospital emergency services and in emergency medical care units in Samsun: an epidemiological study. Ulusal travma ve acil cerrahi dergisi= Turkish Journal of Trauma & Emergency Surgery: TJTES, 2008; 14 (3): 239–244. Chan AOM, Chan YH. Awareness and utilization of peer support programs in Singapore public general hospitals. Int. J. Emerg. Ment. Health 2012; 14: 217–224. Chan AOM, Chan YH, Kee JPC. Exposure to crises and resiliency of health care workers in Singapore. Occup. Med. (Lond.) 2013; 63: 141–144. Choiniere JA, MacDonnell J, Shamonda H. Walking the talk: insights into dynamics of race and gender for nurses. Policy Polit. Nurs. Pract. 2010; 11: 317–325. Cleary M, Horsfall J, Jackson D. Role models in mental health nursing: the good, the bad, and the possible. Issues in Mental Health Nursing. 2013; 34 (8): 635–636. Cleary M, Horsfall J, Muthulakshmi P, Happell B, Hunt GE. Career development: graduate nurse views. J. Clin. Nurs. 2013a; 22: 2605– 2613. Cleary M, Horsfall J, Muthulakshmi P, Jackson D. A good day in nursing: views of recent Singaporean graduates. Contemp. Nurs. 2013b; 45: 126–133. Coffey A, Atkinson P. Making Sense of Qualitative Data: Complementary Research Strategies. Thousand Oaks, CA: Sage Publications, 1996. Cohen EL, Wilkin HA, Tannebaum M, Plew MS, Haley LL Jr. When patients are impatient: the communication strategies utilized by emergency department employees to manage patients frustrated by wait times. Health Commun. 2013; 28: 275–285. Crilly J, Chaboyer W, Creedy D. Violence towards emergency department nurses by patients. Accid. Emerg. Nurs. 2004; 12: 67–73. Delaney J, Cleary M, Jordan R, Horsfall J. An exploration investigation into the nursing management of aggression in acute psychiatric settings. J. Psychiatr. Ment. Hlt. 2001; 8: 77–84. Gantz NR, Sherman R, Jasper M, Choo CG, Herrin-Griffith D & Harris K. Global nurse leader perspectives on health systems and workforce challenges. Journal of Nursing Management 2012; 20: 433–443. Gillespie GL, Gates DM, Miller M, Howard PK. Emergency department workers’ perceptions of security officers’ effectiveness during violent events. Work 2012; 42: 21–27. Gillespie M, Melby V. Burnout among nursing staff in accident and emergency and acute medicine: a comparative study. J. Clin. Nurs. 2003; 12: 842–851. Hahn S, Hantikainen V, Needham I, Kok G, Dassen T, Halfens RJ. Patient and visitor violence in the general hospital, occurrence, staff interventions and consequences: a cross-sectional survey. J. Adv. Nurs. 2012; 68: 2685–2699. Kowalenko T, Gates D, Gillespie GL, Succop P, Mentzel TK. Prospective study of violence against ED workers. Am. J. Emerg. Med. 2013; 31: 197–205. Lau JBC, Magarey J, Wiechula R. Violence in the emergency department: an ethnographic study (part II). Int. Emerg. Nurs. 2012; 20: 126–132. Lo TW, Chappell D, Kwok SI, Wu J. Workplace violence in Hong Kong, China: nature, impact, and preparedness. Int. J. Offender Ther. Comp. Criminol. 2012; 56: 955–975. Martino VD. Relationship of Work Stress and Workplace Violence in the Health Sector: ILO/ICN/WHO Joint Programme Working Paper. Geneva: International Labour Office/International Council
Conclusion This study has contributed to the understanding of ED nurses’ experiences of the physical and psychological effects of having to care for aggressive patients. Similar to other studies, the nurse participants reported aggressive incidents to be relatively common in the ED. Despite being at the receiving end of aggression, the nurses held strongly to their professional role and responsibilities. Support from colleagues was sought by participants, and formal workplace debriefing and counseling were perceived to be lacking. Nurses urged for more organizational support to mitigate workplace patient aggression. Further discussion and research are required to better support nurses to deliver optimal care for aggressive patients, and to achieve positive and effective outcomes.
ACKNOWLEDGMENTS We would like to thank Dr Lau Ying for her assistance with obtaining the ethics approval, Sister Tho Poh Chi, Sister Liang Sufang, and Dr Siti Zubaidah for facilitating access to the clinical area, and staff nurse Claudia Tan for her valuable help during the recruitment phase of the study.
CONTRIBUTIONS Study Design: MFT, MC. Data Collection and Analysis: MFT, VL, MC. Manuscript Writing: MFT, VL, MC.
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of Nurses/World Health Organization Public Services International Joint Programme on Workplace Violence in the Health Sector, 2003. Morse JM, Field PA. Nursing Research: The Application of Qualitative Approaches. London: Chapman & Hall, 1996. Needham I, Abderhalden C, Halfens Phd RJG, Fischer JE, Dassen T. Non-somatic effects of patient aggression on nurses: a systematic review. J. Adv. Nurs. 2005; 49: 283–296. Omansky GL. Staff nurses’ experiences as preceptors and mentors: an integrative review. J. Nurs. Manag. 2010; 18: 697–703. Pich J, Hazelton M, Sundin D, Kable A. Patient-related violence against emergency department nurses. Nurs. Health Sci. 2010; 12: 268–274. Pinar R, Ucmak F. Verbal and physical violence in emergency departments: a survey of nurses in Istanbul, Turkey. J. Clin. Nurs. 2010; 20: 510–517. Spector PE, Zhou ZE, Che XX. Nurse exposure to physical and nonphysical violence, bullying, and sexual harassment: a quantitative review. Int. J. Nurs. Stud. 2014; 51: 72–84.
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Tang JS, Chen CL, Zhang ZR, Wang L. Incidence and related factors of violence in emergency departments – a study of nurses in Southern Taiwan. J. Formos. Med. Assoc. 2007; 106: 748–758. Wolf LA, Delao AM, Perhats C. Nothing changes, nobody cares: understanding the experience of emergency nurses physically or verbally assaulted while providing care. J. Emerg. Nurs. 2014; 40: 305–310. Wong LL, Ooi SBS, Goh LG. Patients’ complaints in a hospital emergency department in Singapore. Singapore Med. J. 2007; 48: 990–995. Yusuf F, Hendriks MM, Tay SE, Kandasamy R, Selvarani S, Phu HH. The impact of verbal abuse on staff working in the psychiatric wards. Singapore Nurs. J. 2006; 33: 31–36. Zampieron A, Galeazzo M, Turra S, Buja A. Perceived aggression towards nurses: study in two Italian health institutions. J. Clin. Nurs. 2010; 19: 2329–2341. Zapf D. Emotional work and psychological well-being: a review of the literature and some conceptual consideration. Hum. Resour. Manage. R. 2002; 12: 237–268.
Nursing and Health Sciences (2015), 17, 307–312
Research Article
Nursing management of aggression in a Singapore emergency department: A qualitative study Mei Fen Tan, BSc (Nursing) (Hons),1 Violeta Lopez, RN, PhD2 and Michelle Cleary, RN, PhD3 1 Neuroscience Intensive Care, Tan Tock Seng Hospital, 2Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore and 3School of Nursing and Midwifery, University of Western Sydney, Sydney, New South Wales, Australia
Abstract
In Singapore, anecdotal evidence suggests that nurses are concerned about managing aggressive incidents in the emergency department. In this study, registered nurses’ perceptions of managing aggressive patients in an emergency department were explored. Ten registered nurses from the emergency department of an acute public hospital in Singapore were interviewed. Four overarching themes emerged from the thematic analysis: (i) impact of aggressive patients on nurses; (ii) nursing assessment of aggressive behaviors; (iii) nursing management of aggressive behaviors; and (iv) organizational support and responsiveness. Further research is required to better support nurses to deliver optimal care for aggressive patients and achieve positive and effective outcomes.
Key words
aggression, education, emergency department, management, nurse, Singapore.
INTRODUCTION Workplace aggression refers to “incidents where employees are abused, threatened or assaulted or subjected to other offensive behavior in circumstances related to their work” (Martino, 2003, p. 5). Aggression in the healthcare sector has been a concern for many years, especially among the nursing profession. Globally, one-third of the nursing population experience some form of workplace aggression in any 12 month period, two-thirds of nurses experience nonphysical violence, and one-quarter experience sexual harassment (Spector et al., 2014). The emergency department (ED) is noted as a high-risk area for workplace aggression. For example, in Australia, emergency nurses reported 110 episodes of violence within a 5 month period, with 37% occurring on the evening shift (Crilly et al., 2004). Research shows, ED nurses experienced physical injuries resulting in psychological effects, such as anger, burnout, stress, anxiety, and fear (Gillespie & Melby, 2003; Needham et al., 2005). Nurses were concerned about their perceived inability to predict patients’ behaviors and future violent incidents (Canbaz et al., 2008). A review of the literature found that a sense of apathy by nurses or their managers has contributed to the underreporting of workplace aggression (Pinar & Ucmak, 2010; Wolf et al., 2014). Deficits in administrative and policy-based practices are also noted (Choiniere et al., 2010; Pich et al.,
Correspondence address: Michelle Cleary, School of Nursing and Midwifery, University of Western Sydney, Locked Bag 1797, Penrith, NSW 2751, Australia. Email: [email protected] Received 10 July 2014; revision received 13 October 2014; accepted 31 October 2014
© 2015 Wiley Publishing Asia Pty Ltd.
2010); for example, ED nurses in Taiwan report that restricting visitors’ access to ED leads to physical aggression (Tang et al., 2007).While aggression-management training is recommended for nurses, evidence suggests that the implementation of a one-time aggression training program is inadequate, and that the content could be more practical (Delaney et al., 2001; Pich et al., 2010). In Singapore, the nursing profession is predominantly female, there is a shortage of registered nurses (RN), and the nursing workforce has a strong work ethic, typically working long hours to meet tight deadlines (Cleary et al., 2013a,b). According to Gantz et al., (2012), Singapore has a younger nursing workforce than in most developed countries, and there is substantial attrition of nurses within the first three years of their career related to the less-than-ideal working environment. Anecdotal evidence suggests there is an absence of policy in support of an aggression-free workplace (zero-tolerance legislation, prevention strategies, and mandatory training in aggression management), which differs to many Western nations (Pich et al., 2010). There is also a paucity of research in relation to patientrelated aggression toward nurses, especially in ED. Research by Chan et al. (2013) found that patient and/or relative aggression is the most common type of work-related aggression experienced by healthcare workers. A peer-help, multicomponent crisis response-management system has been made available by the Ministry of Health to Singapore public general hospitals since 2008, but a multisite healthcare workers survey by Chan and Chan (2012) revealed that only 10.6% of nurses have used the system to seek emotional support for work-related aggression. To date, there is only one research study that actually focused on aggression in doi: 10.1111/nhs.12188
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Singapore (Yusuf et al., 2006); the restricted scope of the investigation (verbal aggression and psychiatric hospital) limits the applicability of the findings to other general hospitals. ED are a high-risk area for aggression, and abuse toward nurses is relatively common, accepted as part of the job, and embedded in the culture (Pich et al., 2010). Current evidence points to the need to further explore nurses’ perspectives of how best to care for people exhibiting aggressive behaviors, which could contribute to efforts in reducing the adverse effect on nurses and identify the impediments for the required changes by organizations or individual healthcare professionals (Cohen et al., 2013; Hahn et al., 2012; Needham et al., 2005; Pich et al., 2010). It is against this background that the present Singaporean study was developed. In this study, ED nurses’ perceptions of managing aggressive patients were explored. Although there have been a number of studies that have focused on the impact of patients’ aggressive behaviors in nurses, this qualitative study is the first in Singapore to explore nurses’ perceptions of managing aggressive patients presenting to the ED.
METHODS The setting for this study was a 24 h ED at a major Singapore general acute hospital, with separate ED facilities for adult and pediatric patients. The inclusion criteria were RN who had prior contact with aggressive patients and had worked in the adult ED setting less than three months. For the protection of human participants, approval for this study was obtained from the National Healthcare Group Domain Specific Review Board. Advertisement flyers and a staff briefing were used to recruit potential participants. Interviews were arranged at a mutually-agreed venue and time, and all participants provided written consent after they all understood the nature and purpose of the study. The interview guide was adapted from a previous study (Delaney et al., 2001), with permission granted before being piloted with two colleagues. Interview topics included demographics, assessment of aggression, nursing interventions, communication skills, education and training, de-escalation and physical restraint skills, post-aggressive incident support and follow up, and other issues or relevant factors. The interviews were conducted in English and all were digitally recorded, with each lasting between 30 and 60 minutes. The principle of data saturation was adopted to establish sample size; that is, until interview content became repetitive and unlikely to generate new information from further data collection (Morse & Field, 1996). Data collection and analysis proceeded simultaneously (Coffey & Atkinson, 1996). Verbatim transcriptions of the data were analyzed according to the tenets of thematic analysis and included becoming familiar with the data, generating initial codes, searching for and reviewing themes, defining and naming themes, and producing the report (Braun & Clarke, 2006). These steps provided a systematic process for the researcher to conduct the thematic analysis and develop themes from the interview data. © 2015 Wiley Publishing Asia Pty Ltd.
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RESULTS Ten RN aged 22–30 years were interviewed, and eight (80%) were female. The participants had spent their entire nursing career in the ED, and had 2–8 years of working experience. Three (30%) participants were diploma holders, four (40%) had an advanced diploma, and three (30%) had attained a bachelor degree as their highest nursing qualifications at the point of data collection. The thematic analysis yielded four themes: (i) impact of aggressive patients on nurses; (ii) nursing assessment of aggressive behaviors; (iii) nursing management of aggressive behaviors; and (iv) organizational support and responsiveness.
Impact of patients’ aggressive behaviors on nurses ED nurses reported that caring for aggressive people affected them psychologically and physically. The psychological effects included feeling upset, not feeling appreciated, and having recurrent thoughts about what could be done better. The frequent exposure to aggression created job dissatisfaction, resentment, and regrets about initiating the interaction with the person. Some of the nurses also reported feeling burned out and wearisome about continuing with their work duties: I was punched . . . it was quite painful. So I kept thinking what can I do better? Why must I go and attend to that patient? Sometimes I feel like I should just ignore that person. (Participant 3) Fracture was also reported as a consequence of aggression, and the majority of nurses were not always able to prevent aggressive incidents. As a result of the physical injuries sustained, nurses were not always able to complete their nursing duties and were required to take sick leave.
Nursing assessment of aggressive behaviors An integral part of managing aggression is the ability of nurses to employ various nursing-assessment strategies. In this study, nurses during their clinical encounter with aggressive people used presenting information and previous history, as well as nurses’ reflection on past experiences to assess the person. They also relied on the medical diagnoses (i.e. alcohol intoxication, delirium) to determine the possibility for aggressive behavior. All interviewees indicated that alcohol intoxication contributed to a higher likelihood of aggressive behaviors. Nurses also attributed possible underlying medical conditions, such as sepsis, electrolyte imbalances, heat stroke, dementia, and seizures, to aggressive behavior. Several nurses also reported that if they receive information on a patient admitted with a drug overdose or a risk of self-injury during the handover of care, they would consider these patients to be potentially aggressive. Nurses also used their observation skills as part of the routine assessment for potentially-aggressive people. Specifically, nurses observed body language, verbal cues, and signs of unhappiness or dissatisfaction via the content, tone, and volume of the patient’s speech:
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You can observe their behavior is a bit abnormal when a patient starts to shout and (they) don’t obey your commands. Potentially, they will be difficult to manage. (Participant 10)
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also resorted to seeking help from the security department when they were unable to satisfactorily manage the aggressive situation:
The nurses were quick to determine that those with the aforementioned presentations would have some form of risk for aggression in addition to being regular users of the ED:
We (nurses] call the security to come . . . You can’t possibly sedate an alcohol-intoxicated patient because . . . they will get more sedated . . . you can’t physically restraint them too, because they are . . . (still) conscious and they are quite strong. (Participant 8)
I already know that this patient tends to be aggressive, because they already have a history, or I have already seen them being aggressive . . . we have regular patients, drunk patients, who regularly turn up in our department. (Participant 9)
Nurses reported contacting the police if it was perceived to be a case of severe physical aggression or when the person threatened the nurse. Nurses urged for changes so that they were more supported:
The nurses reported making quick judgements to categorize patients, as the use of chemical or physical restraints might be necessary to effectively manage aggressive incidents.
Nursing management of aggressive behaviors Despite sustaining injuries, nurses spoke about their professional obligations and the importance of upholding standards and good service. These nurses also reported making extra efforts to interact with aggressive people, even when they were reluctant to do so: You need to . . . be nice to them, but not too nice (to the extent) you do everything for them . . . just be nice to them, do whatever you need to do. (Participant 1) Caring for aggressive people was deemed to be time intensive. As a result, the majority of nurses believed that they could not do what they should do for all persons in their care. Across all the interviews, nurses adopted a stoic stance on the issue of aggression, and viewed dealing with aggressive incidents to be part of their job. Nurses perceived that they could manage the challenges of caring for aggressive people, despite the potential for physical or psychological injury: I’m not affected that much, because I think it (aggression) is normal inside ED, and people come in with these kinds of conditions. (Participant 2) However, some nurses reported instances where they or their colleagues were unable to maintain professionalism:
I called (the police) to come and help me because it is a very violent patient in the department. So after taking down my report . . . they asked me, “Do I want to pursue the matter?” . . . I was thinking . . . why am I given a choice to pursue this matter? Can’t they choose to pursue them instead of me charging him for doing all these violence and vulgarities? Because if I pursue this matter, they told me, it is under civil law and I sue him accordingly. (Participant 7) It was also noteworthy that other than managing aggressive incidents, nurses also needed strategies to be able to let go of negative emotions. Many nurses explained that their coping strategies had helped, and examples they gave included venting to colleagues and family, separating professional duties from one’s personal life, and engaging in regular leisure activities.
Organizational support and responsiveness According to the ED nurses, debriefing sessions conducted after incidents were infrequent, and sometimes there were none at all. For incidents that were perceived as inconsequential, nurses reported that the nurse managers did not show concern or render support. Inconsequential incidents appeared to be justified and normalized by the high frequency of aggressive incidents. Most of the nurses sought support from colleagues – “counseling each other” – to cope with the emotional effects. They expected front-line leaders, such as senior nurses, to have the competency to manage aggressive incidents and to be their role models:
Of course, at the scene, we are very angry . . . We . . . shout at the patient: “Hey you don’t – you must obey us”. (Participant 3)
I need the help of my senior nurses to teach me . . . how to properly manage (aggressive patients) or how to decide what interventions to use (in aggression management). (Participant 4)
Nurses had proactively offered to take over the responsibility for care in the few instances in which they observed their colleagues being unable to maintain their professionalism toward patients. Frequent interaction with patients was deemed important to prevent aggression, including providing information and updates. This included using hospital translators if language was deemed a communication barrier. Chemical and physical restraints were used to manage aggression to ensure safety and allow the healthcare staff to carry out important investigations and treatments. Nurses
Besides senior nurses, male nurses tend to step forth to assist in aggressive incidents. Not all nurses reported being familiar with the available guidelines, policies, and procedures that could help them manage aggressive incidents. It was suggested that the guidelines should provide a systematic form of assessment to identify people who can potentially turn aggressive. However, current guidelines, protocols, and policies provided directions on when to call the police and seek help. It appears that most nurses filed police reports when they received verbal threats from their patients: © 2015 Wiley Publishing Asia Pty Ltd.
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One patient said: “You don’t let me see you outside the hospital. I’ll kill you if I see you”. So because of this case, we made a police report. Because it is (a) threat and you won’t know if he really will come back and kill you, because he can just wait outside for you in (this hospital), then . . . follow you home. (Participant 6) As part of the ED’s protocol, it was mandatory for nurses to write incident reports for incidents of physical aggression. Similar to incidents of verbal aggression, nurses reported that the decision to complete a report was at their discretion. Across all interviews, nurses believed that incident reports were important and necessary to avert legal liabilities in the event of alleged negligence or complaints against the nurse: Because the patient is threatening us . . . we really have to do write something in the incident report . . . if ever the patient sues us or writes a complaint letter, we have this written report of what really happened that time, that day. (Participant 5) Despite the importance of incident reporting, nurses found the process cumbersome. They also perceived that management rarely acted on reports or provided additional resources to support nurses in managing aggressive incidents. Workplace education, preparation, and training were deemed important to prepare nurses in ED for their role in managing aggressive behaviors. Some nurses stressed the importance of actual workplace experience in gaining skills, knowledge, and confidence: I think the experience gained from working here will help you . . . It is better than any course . . . there is no course that can teach you. It is just valuable experience. (Participant 6)
DISCUSSION ED nurses’ experiences of the impact of patients’ aggression, as well as their perceptions of managing aggressive patients, were explored in this study.The findings resonated with many other studies about the myriad of consequences ED nurses experience from aggressive encounters (Gillespie & Melby, 2003; Zampieron et al., 2010). Nurses in this study reported bodily injuries (e.g. being hit, kicked, and pushed), and verbalized reluctance in caring for aggressive people, although acknowledging their professional obligation to care for such people.The findings regarding these negative effects resonate with the literature, including feeling burned out (Gillespie & Melby, 2003; Lau et al., 2012; Lo et al., 2012; Chan et al., 2013; Kowalenko et al., 2013). The nurses were able to identify potentially-aggressive people when they factored the patient’s medical or nonmedical presentation into account. The findings of this study are supported by previous research. Alcohol intoxication, the use of drugs/drug overdose, as well as the presence of mental illness were cited by nurses as contributing to aggressive incidents (Crilly et al., 2004). Similarly, nurses cited medical conditions as biomedical cues to determine the aggression risk of patients. Health service-related reasons, such as long waiting times or patients seeking ED admission due to socio© 2015 Wiley Publishing Asia Pty Ltd.
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economic reasons, could also result in patients exhibiting aggressive behaviors. Previous research has reported similar findings, where nurses perceived that people who could not tolerate the long waiting times were potential aggressors (Wong et al., 2007; Wolf et al., 2014). This problem is also attributed to the current setting in this study, where waiting times to see a doctor could vary between 4 and 10 h. Strategies to decrease waiting times are currently being reviewed in this setting. In this study, nurses also depended on the recall of past experiences to identify potential aggressors. These were people whom they have had previous aggressive encounters with. Observation skills were particularly useful for nurses in this study in identifying behavioral cues for potential aggressors. It might be useful if ED nurses in Singapore consider formal assessment tools to guide their assessment for aggression risk, and this warrants further consideration. Nurses in this study perceived the care of aggressive people as part of their everyday work duties; this was justified by the common occurrence of aggression in their workplace. The challenge for ED nurses was maintaining their professionalism during an aggressive encounter. As part of their professional code, nurses are required to embody core values of care and empathy, although it might prove difficult to express naturally in non-ideal situations (Zapf, 2002; Spector et al., 2014), especially when dealing with people who might not be appreciative of the nurses’ efforts. Nurses urged for the development of resources in order to help them cope with the challenges in the workplace, and they valued security and police as aggression-management resources. Similar to previous studies, nurses reported that most of the security guards were quick in their arrival and assisted the nurses during aggressive incidents (Gillespie et al., 2012). However, more organizational efforts are needed in ensuring a reliable security workforce that can readily assist in aggressive incidents. As demonstrated in the findings, nurses acquired aggression-management skills by learning from other more experienced nurses when transitioning to the workplace as graduate nurses. The benefits of role modeling are noted in the literature (Omansky, 2010; Cleary et al., 2013). Nurses recommended aggression-management training programs to enhance their confidence, as well as the need to strengthen current induction programs. Most of the nurses mentioned the use of current guidelines, protocols, and policies in guiding their nursing care of aggressive patients in this study. However, they expressed a need for further organization support to enhance the available support and network system for staff who encounter or work with aggressive patients, including the provision of a formal debriefing system.
Study limitations As with all studies, there are a number of limitations for this research project. The project was conducted at a single site with a small group of ED nurses. Further, findings explored registered nurses’ experiences in one emergency department in Singapore, and therefore, are restricted in scope and transferability, especially in Western countries.
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Implications for nursing practice
REFERENCES
Consistent with international reports, workplace aggression appears to be relatively common in the ED and needs to be addressed to avert its physical and psychological effects on nurses, as well as other healthcare workers in the ED. In this study, nurses’ awareness of patients who might be potentially aggressive was mainly based on past experiences. However, there is a need for a more reliable and valid way of assessing these patients, and such a tool should be used as part of a routine assessment of all patients presenting in the ED. The study also highlights the need for more thorough education programs, not only to prepare nurses in handling aggression at the workplace, but also other work-related crises. Such programs must be well structured, evidence based, and multidisciplinary focused, and should be provided during the orientation of new healthcare workers and as needed. Management is also encouraged to provide a supportive environment for staff who experience aggressive behaviors, so as to encourage staff to report all incidents and be assured that they will be acted upon. The long waiting times of patients in the ED are a worldwide problem that contributes to aggression. All ED should explore the factors that contribute to the long waiting times and implement strategies to improve the flow of patients more effectively. The role of the multidisciplinary team, including security officers, must also be acknowledged and warrants further exploration and research.
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Conclusion This study has contributed to the understanding of ED nurses’ experiences of the physical and psychological effects of having to care for aggressive patients. Similar to other studies, the nurse participants reported aggressive incidents to be relatively common in the ED. Despite being at the receiving end of aggression, the nurses held strongly to their professional role and responsibilities. Support from colleagues was sought by participants, and formal workplace debriefing and counseling were perceived to be lacking. Nurses urged for more organizational support to mitigate workplace patient aggression. Further discussion and research are required to better support nurses to deliver optimal care for aggressive patients, and to achieve positive and effective outcomes.
ACKNOWLEDGMENTS We would like to thank Dr Lau Ying for her assistance with obtaining the ethics approval, Sister Tho Poh Chi, Sister Liang Sufang, and Dr Siti Zubaidah for facilitating access to the clinical area, and staff nurse Claudia Tan for her valuable help during the recruitment phase of the study.
CONTRIBUTIONS Study Design: MFT, MC. Data Collection and Analysis: MFT, VL, MC. Manuscript Writing: MFT, VL, MC.
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