Copyright © eContent Management Pty Ltd. Contemporary Nurse (2014) 49: 113–121.
Prevalence and characteristics of aggression and violence experienced by Western Australian nursing students during clinical practice Martin Hopkins, Catherine M Fetherston and Paul Morrison School of Health Professions, Murdoch University, Perth, WA, Australia
Abstract: Aim: To identify the prevalence and characteristics of aggression and violence experienced by undergradu-
ate nursing students in the clinical setting. Method: A cross sectional survey of second (N = 97) and third (N = 56) year nursing students in a Western Australian University was conducted. Data were analysed using frequencies, percentages and means (standard deviation) and independent samples t-test for between group differences. Results: Over 58% (N = 55) of second year and 57% (N = 32) of third year nursing students experienced some kind of non-physical violence. Various forms of physical violence were also reported by over a third (N = 33) of the second year and 25% (N = 18) of the third year nursing students. Conclusion: This study has identified nursing students are exposed to, and feel at significant risk of, aggression and violence in the clinical setting. Providing them with an appropriate level of knowledge and self-confidence to assist in the management of the threat and actuality of such incidents is essential.
Keywords: physical, non-physical, aggression, violence, nursing student, prevalence
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ggression and violence is a significant problem and is witnessed in all aspects of modern society. This is evident in the everyday exposure experienced by people to aggressive and violent incidents via media, such as television, newspapers, radio and games, as well as in their personal lives (Garnham, 2001). There are no borders or boundaries concerning aggression and violence and incidents occur in all countries, cultures, races, ages and contexts. The global increase in violence and aggression is impacting public health systems dramatically (McEwan, 2012; van den Bossche, 2013). This is evidenced in the US healthcare setting, where violence is said to account for 45% of all workplace related incidents (McEwan, 2012), whist in Australia, the health care setting has been identified as the most violent working environment (Perrone, 1999; Pich, Hazelton, Sundin, & Kable, 2010). It is widely accepted that nursing is one of the highest risk jobs for encountering violence and aggression (Gerberich et al., 2005; Pich, Hazelton, Sundin, & Kable, 2011) and staff within the profession are deemed at higher risk of violence and aggression than even police and prison officers (Perrone, 1999). Nurses are four times more likely to experience a violent attack than any other health care worker (Wells & Bowers, 2002) and it has been suggested that at some point in their
careers, all nurses will be involved in a violent or aggressive situation (Yassi, 1994). Research undertaken over the past two decades and in a number of countries, including the UK, Turkey, Germany and Israel (Bronner, Peretz, & Ehrenfeld, 2003; Celik & Bayraktar, 2004; Nau, Dassen, Halfens, & Needham, 2007) shows that nursing students were also being subjected to violence and aggression in the clinical setting and may indeed be at higher risk of exposure than other healthcare workers. However no studies have investigated the prevalence and types of violence and aggression being experienced by nursing students in Australia. This knowledge is essential if we are to appropriately prepare our nursing students to deal with these adverse incidents. There are many forms of aggression and violence and consequently there is much debate in the literature as to what constitutes an appropriate definition. The terms aggression and violence are subjective in nature and this therefore, adds to the difficulties associated with assigning a specific definition to encompass the spectrum of behaviours by which it is represented (Hegney, Plank, & Parker, 2003). In an attempt to provide a comprehensive operational definition for the study, minimise confusion on the part of participants and reduce the subjectivity associated with the terminology, workplace aggression and violence was
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divided into physical and non-physical elements, as defined by the Western Australian Department of Health (2004) (Figure 1). Objectives of this study The results presented here are part of a larger study that compared two previously untested paedagogies designed to build resilience and increase positivity in nursing students when encountering aggression and violence in the clinical setting. As part of this study one of the objectives was to investigate the prevalence and characteristics of aggression and violence experienced by undergraduate nursing students in a Western Australian university during exposure to workplace learning.
The third year nursing students had attended at least four clinical practicums, including mental health and acute care placements. No exclusion criterion was invoked and students had the right to refuse to participate.
Methodology A cross sectional survey was used to collect demographic and descriptive data on prevalence and nursing student’s experiences of violence and aggression in the clinical setting. Demographic data collected included participant’s age, gender, marital status, combined annual household income, hours of paid employment per week and number of children. Participants were also asked to rate their perceived level of risk of physical and non-physical Sample This study used purposive sampling with the aggression and violence and then indicate if they sample frame consisting of all second and third had ever experienced any physical or non-physical year undergraduate nursing students enrolled in a aggression and violence during placements. The core nursing unit in a 3-year Bachelor of Nursing rating scale responses on the 1–5 scale for level of Program at a Western Australian metropolitan risk were 1 = never to 5 = all of the time. Specific University in semester one, 2013. The second year questions regarding experiences with violence and students had only experienced two clinical prac- aggression included frequency of incidents, time tice placements prior to completion of the survey, since last incident, perpetrator, form of aggression both of which were in the aged care environment. and violence, any injury sustained and if any time off work was required as a result of the incident. All information Workplace aggressive behaviour: incidents, perceived or real to individuals, when sought was within the context of the participant’s workplace they are abused, threatened or assaulted in circumstances arising out of, or in the experience as a nursing student course of their employment, involving an explicit or implicit challenge to their and no information was gathered safety, health or wellbeing. relating to personal experiences outside this context. Workplace violence: an action or incident that physically or psychologically harms Prior to the data collection another person. It includes situations where employees and other people are phase of the study the questhreatened, attacked or physically assaulted at work. tionnaire was pilot tested with a group of third year nursNon-physical violence such as verbal abuse, intimidation and threatening ing students for face validbehaviour, may also significantly affect a person’s health and wellbeing. Threats ity and appropriateness of the may be perceived or real and there does not have to be physical injury for the questions (Maltby, Williams, McGarry, & Day, 2010). The violence to be a workplace hazard. Employees may be affected by workplace questionnaire was also tested violence even if they are not directly involved. for face validity by six of the Department of Health Prevention of Workplace Aggression and Violence Policy and Guidelines (2004) authors’ professional colleagues with backgrounds in emergency care, aged care, mental health care and midwifery. Items for Figure 1: Definition of aggression and violence 114
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Prevalence and characteristics of aggression and violence experienced inclusion in the questionnaire were drawn from the literature and focussed on helping to answer some of the primary research questions. Analysis was conducted using PASW, SPSS Statistics version 21 for Windows (IBM, 2012) with descriptive data reporting frequencies, percentages and either median and interquartile range or mean and standard deviation (SD) according to normality. Independent samples t-test was used to compare between groups differences. All p levels lower than 0.05 were considered significant. Approval for the study was granted by Murdoch University Human Research Ethics Committee (2012/126).
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Demographic characteristics Participants were predominantly female with a broad range of ages from 17 to 54 years (mean 29.8), with the majority under 45 years and without children. Annual family income did differ between year groups with more third year than second year students reporting an income over $100,000 although this was not statistically significant (p = 0.407). Approximately a quarter of third year students and a third of second year students earned 44 years stabbing (Table 2). Almost Annual family income (AFI) all of the instances of physi37.2% (N = 35) 29.4% (N = 15) $100,000 rarely felt at risk of physical Number of children violence with the remaining 0 48.9% (N = 46) 53.7% (N = 29) 45% feeling at risk either 1 4.3% (N = 4) 9.3% (N = 5) sometimes, often, or all the 2 24.5% (N = 23) 16.7% (N = 9) time (Table 3). Similarly 3 14.9% (N = 14) 9.3% (N = 5) nearly 60% of third year stu 4 3.2% (N = 3) 7.4% (N = 4) dents said they either never 4.4% (N = 4) 3.7% (N = 2) >4 or rarely felt at risk of physiHours of paid employment 9.62 ± 9.93* 11.70 ± 11.40* cal violence in the workplace *Mean and SD. with the remaining 40%
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violence during clinical practice with all of the students experiencing non-physical aggression Type of physical Second year Third year and violence more than once aggression experienced students (N = 97) students (N = 56) (Table 4). The perpetrator was Grabbed 30.3% (N = 10) 27.8% (N = 5) predominantly the patient but Pushed 3% (N = 1) 5.6% (N = 1) other healthcare workers were Bitten 6.1% (N = 2) Nil also identified (Table 4). Just Punch/attempted punch 36.4% (N = 12) 50% (N = 9) under half the students reported Object thrown 9.1% (N = 3) 5.6% (N = 1) that they either never or rarely felt Slap Nil 5.6% (N = 1) at risk of non-physical violence Kicked Nil 5.6% (N = 1) whereas 58% felt at risk either Attempted stabbing 3% (N = 1) Nil sometimes, often or all the time 34% (N = 33) 32.7% (N = 18) Total reporting any form (Table 5). of physical aggression A similar number and type of and violence the non-physical incidents expePerpetrator rienced by second years were Patient Colleague 97% (N = 32) 88.9% (N = 16) also reported by third years with Registered nurse 3% (N = 1) 11.1% (N = 2) 57% having experienced nonphysical violence. Sixty three percent were exposed to such Table 3: Perceived risk of physical aggression and violence an incident on more than one of student participants (N = 152) occasion (Table 4). Only a third Level of perceived risk Second year Third year stated that they either never or of physical aggression students (N = 97) students (N = 55) rarely felt at risk of non-physical and violence violence whereas 66% felt at risk either sometimes, often or all the Never 9.3% (N = 9) 20% (N = 11) time (Table 5) with 71% of inciRarely 45.4% (N = 44) 38.2% (N = 21) dents occurring within the last Sometimes 35.1% (N = 34) 34.5% (N = 19) 12 months. The third year stuOften 8.2% (N = 8) 5.5% (N = 3) dents reported similar perpetraAll the time 2.1% (N = 2) 1.8% (N = 1) tors to the second year students although there was a slightly feeling at risk either sometimes, often or all the increased incidence of healthcare workers identime. Actual physical violence was reported by tified (Table 4). 25% of students, of whom more than half expeIt was reported by both third year and second rienced the abuse in the last 12 months, with the year students that, as a direct result of the effects patient being the main perpetrator (Table 2). of the non-physical aggression and violence, time The physical violence experienced by the stu- off work was required. dents resulted in four of the second year students and two of the third year students sustaining an Discussion injury. These injuries resulted in five of the stu- The prevalence and characteristics of aggression dents requiring time off work. The type of injury and violence affecting Australian nursing students was not specified. in the workplace is reported in this paper for the first time, and indicates there is significant cause for concern. It is clear from this study’s findings Non-physical violence and aggression Just over 58% of the second year nursing students that a significant number of nursing students are reported a history of experiencing non-physical affected by workplace aggression and violence, Table 2: Type of physical aggression incidents (N = 51) experienced by year of student
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Prevalence and characteristics of aggression and violence experienced
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and violence’. This study sought to ensure a comprehensive definition encompassing both physical and non-physical aggression (Figure 1) to Second year Third year Frequency of nonstudents students physical aggression guide the participants in their survey (N = 48) (N = 30) and violence answers. This allows for greater accuracy and reproducibility of findings One occasion Nil 36.7% (N = 11) and provides the potential for a betGreater one occasion 100% (N = 48) 63.3% (N = 19) ter understanding of the scale of the Number of incidents 6.19 ± 16.08* 6.30 ± 10.28* problem to which nursing students 58.5% (N = 55) 57.1% (N = 32) Total reporting any are exposed. non-physical aggression The findings from this current study, and violence Third year Second year Perpetrator of nonin relation to the prevalence of physical students students physical aggression violence and aggression, are supported (N = 33**) (N = 54) and violence by a similar, although less recent, Patient 85.2% (N = 46) 60.6% (N = 20) report from the US of registered nurses Patients relative 3.7% (N = 2) 9.1% (N = 3) (Nachreiner, Gerberich, Ryan, & Registered nurse 3.7% (N = 2) 18.2% (N = 6) McGovern, 2007). As expected prevaCare assistant 5.6% (N = 3) 9.1% (N = 3) lence amongst registered nurses has Colleague 1.9% (N = 1) Nil been reported as even higher in more Clinical educator Nil 3% (N = 1) recent studies and ranges from 42% *Mean and SD; **some students reported more than one perpetrator. in Switzerland (Hahn et al., 2010) to 81% in Turkey (Erkol, Gokdogan, Table 5: Perceived risk of non-physical aggression and violence Erkol, & Boz, 2007). of student participants (N = 153) The consequences of physical violence in the healthcare environSecond year Third year Level of perceived risk of ment is often the focus of aggression students students non-physical aggression (N = 97) (N = 56) and violence and violence studies (Kansagra et al., 2008; Paterson, Leadbetter, & Bowie, Never 6.2% (N = 6) 8.9% (N = 5) 2001), however, the prevalence of Rarely 36.1% (N = 35) 25% (N = 14) non-physical aggression and vioSometimes 43.3% (N = 42) 46.4% (N = 26) lence reported in this study exceeded Often 12.4% (N = 12) 17.9% (N = 10) physical forms by over 20%. These All the time 2.1% (N = 2) 1.8% (N = 1) findings are supported in the general aggression and violence literawith similar levels reported as those previously ture (Camerino, Estryn-Behar, Conway, van Der experienced by registered nurses and other health Heijden, & Hasselhorn, 2008; Pich et al., 2011; care workers in the United Kingdom (Grenade & Wells & Bowers, 2002) and the literature that Macdonald, 1995; Winstanley & Whittington, specifically addresses the issue amongst the nurs2004). The high levels of aggression and violence ing student population (Celik & Bayraktar, 2004; reported in this study has the potential to nega- Ferns & Meerabeau, 2008). The finding that over tively impact students’ physical and psychologi- half the students surveyed reported experiences of cal health, as well as impact workforce retention non-physical aggression is similar to findings in in the future. It is difficult to understand the full Turkey, Germany and Israel (Bronner et al., 2003; extent of the prevalence of aggression and vio- Celik & Bayraktar, 2004; Nau et al., 2007), with lence nurses and nursing students are exposed to the study from Turkey reporting that all students due to the participant subjectivity and potential surveyed had experienced some verbal aggression multiple interpretations of the term ‘aggression (Celik & Bayraktar, 2004). Table 4: Frequency of non-physical aggression and violence experienced by student participants including type of perpetrator (N = 87)
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A second and more recent study from Turkey also confirmed that the problem is continuing and found that over 90% of nursing students subjected to violence (N = 175) had experienced verbal abuse, with patients being the main perpetrators (Çelebioglu, Akpinar, Küçükoglu, & Engin, 2010). What has not been reported so far in the literature, that was evident in this current study, is how at risk of non-physical aggression and violence many nursing students feel. This feeling of risk has the potential to negatively impact their confidence, health and everyday functioning and is an issue that requires immediate attention. A key strategy outlined in the literature that is designed to tackle the problem of workplace aggression and violence is that of education, however, this is predominantly in the postgraduate environment. Most often this education focuses on the use of de-escalation, breakaway and restraint techniques (Rintoul, Wynaden, & McGowan, 2009; Wand & Coulson, 2006), although a recent Australian study attempted to modify staff attitudes towards prevention of violence through education, with limited success (Gerdtz et al., 2013). Education specifically targetted for nursing students in the UK and Germany has been reported (Beech, 2001; Beech & Leather, 2003; Nau, Dassen, Needham, & Halfens, 2009; Nau, Halfens, Needham, & Dassen, 2010). Both studies provided the nursing students with a stand-alone three day course, however, the UK study focussed on communication techniques and personal safety whereas the study by Nau et al. (2009) addressed levels of student coping. Post course analysis provided evidence of increased student awareness and ability to cope with aggression and violence and confidence in dealing with situations. However, reports of the integration of aggression and violence education into an undergraduate curriculum still do not exist. This indicates a need for undergraduate aggression and violence education to be integrated into the nursing curriculum to better prepare nursing students when faced with aggressive and violent incidents in the clinical setting. Perpetrators of both physical and nonphysical violent incidents were predominantly identified in this current study as the patient, 118
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which is similar to previous studies (Nachreiner et al., 2007; Pich et al., 2011), although some of the students in this current study identified registered nurses and colleagues as the perpetrator. Authors reporting on bullying in the nursing profession (Longo, 2007; Rowe, 2005) have previously commented that nurses have a tendency to ‘eat their young’. However this generalisation was not reflected in the comparatively small numbers of aggressive and violent incidents experienced by the students at the hands of registered nurses. The International Council of Nurses (2006) called for zero tolerance an all forms of aggression and violence, therefore, despite the small numbers involved in this form of incident in this study, no level of physical or non-physical aggression or violence is acceptable, and that acts of aggression and violence perpetrated by those who hold positions of power over vulnerable students are particularly disturbing. Data from this study indicates the length of time spent as a nursing student does not increase the prevalence of physical violence as approximately equal numbers of both second year and third year students reported physical violence since commencing their studies. The second year students surveyed had only been engaged in aged care work placements, supporting the notion that the general ward area, and particularly aged care, is a high risk environment for aggression and violence (Whittington, 1996; Winstanley & Whittington, 2004). Indeed, aged care and nursing home facilities have been identified as areas of significant risk of aggression and violence in the US (Gerberich et al., 2005) and Australia (Hegney et al., 2003). This source of aggression and violence that nursing students are exposed to requires further research. The forms of abuse reported, such as punching and grabbing, were also similar between year groups however one second year student reported an attempting stabbing occurring within the aged care setting, which is of particular concern due to the potential for serious injury and even death. Some of the incidents had a significant negative impact on the students with some requiring time off work due to physical violence (N = 7) and non-physical violence (N = 4). Any reports of aggression and violence are of concern; however, reports of nursing students requiring time
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Prevalence and characteristics of aggression and violence experienced off work clearly have health and economic implications that require addressing. Due to the level and severity of the aggression and violence student nurses are being exposed to it is evident that they require preparation to cope with these events before entering the clinical environment. It is suggested on the basis of the findings from this study that there be a paradigm shift to bring aggression and violence education into the undergraduate curriculum to specifically target the issues experienced by nursing students. Limitations The findings are limited by the setting and generalisability may be problematic within Australia due to variations in the structure of nursing programmes offered at other Australian Universities, particularly where students may attend different clinical placements at different stages of their programmes. However, the authors are confident this limitation was minimised as both second and third year students were surveyed and breadth of clinical experience within nursing programmes in Australia is standardised through accreditation by the Australia Nursing and Midwifery Accreditation Council. Generalisability may also be limited due to the small sample of nursing students drawn from one University and self-selection by students who had experienced aggression and violence could not be ruled out. Self-report data provided may limit the reliability of some responses, including in relation to recall of the frequency of exposure to violence and aggression, and no attribution of causality can be made. Although a definition of workplace violence and aggression was provided in each section of the survey instrument to guide the participants and assist reliability and validity of the data collected, survey responses were nonetheless subject to students’ own perceptions of workplace violence and aggression. The authors sought to minimise such subjectivity through careful selection of a definition chosen to enhance clarity regarding the varying forms of aggression and violence (Chapman & Styles, 2006; Farrell, Shafiei, & Chan, 2013; Luck, Jackson, & Usher, 2006). Conclusion and recommendations This study has identified student nurses are exposed to significant levels of aggression and © eContent Management Pty Ltd
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violence and often feel at risk of aggression and violence in the clinical setting. Clearly action needs to be taken to protect the students and to better prepare them at an undergraduate level to confront these experiences of aggression and violence. This will enable nursing students to enter the clinical setting prepared for potential aggressive and violent events. This study has identified the extent and nature of the problems related to violence and aggression that nursing students are facing and it is recommended that further research be conducted to introduce reporting and support systems involving both placement sites and universities. The aim of introducing reporting systems should be focussed on instigating an investigative process that will have the potential to activate interventions in both the clinical and education environments to aid in supporting and protecting the nursing students. Additionally collaborative, longitudinal studies are required that address the shortfalls in undergraduate aggression and violence training to enable nursing students to deal with these situations and to build resilience to aggression and violence through appropriate education. If targetted correctly, universities have the potential to better prepare nursing students to respond confidently, positively and capably to any violence and aggression encountered in the workplace. Acknowledgements The authors would like to thank the nursing students who participated in this study for their time and effort in completing the surveys. The authors would also like to acknowledge the efforts of the lecturing staff, for providing the time and opportunity for the surveys to be carried out within their units. References
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Bronner, G., Peretz, C., & Ehrenfeld, M. (2003). Sexual harassment of nurses and nursing students. Journal of Advanced Nursing, 42(6), 637–644. Camerino, D., Estryn-Behar, M., Conway, P. M., van Der Heijden, B. I. J. M., & Hasselhorn, H.-M. (2008). Work-related factors and violence among nursing staff in the European NEXT study: a longitudinal cohort study. International Journal of Nursing Studies, 45(1), 35–50. Çelebioglu, A., Akpinar, R. B., Küçükoglu, S., & Engin, R. (2010). Violence experienced by Turkish nursing students in clinical settings: Their emotions and behaviors. Nurse Education Today, 30(7), 687–691. Celik, S. S., & Bayraktar, N. (2004). A study of nursing student abuse in Turkey. Journal of Nursing Education, 43(7), 330–336. Chapman, R., & Styles, I. (2006). An epidemic of abuse and violence: Nurse on the front line. Accident and Emergency Nursing, 14(4), 245–249. Department of Health. (2004). Prevention of workplace aggression and violence policy and guidelines. Perth, WA: Government of Western Australia. Retrieved from http://www.nursing.health.wa.gov.au/docs/ reports/WorkplaceAggression_Violence.pdf Erkol, H., Gokdogan, M. R., Erkol, Z., & Boz, B. (2007). Aggression and violence towards health care providers – A problem in Turkey? Journal of Forensic and Legal Medicine, 14(7), 423–428. Farrell, G. A., Shafiei, T., & Chan, S. P. (2013). Patient and visitor assault on nurses and midwives: An exploratory study of employer ‘protective’ factors. International Journal of Mental Health Nursing, 23(1), 88–96. Ferns, T., & Meerabeau, L. (2008). Verbal abuse experienced by nursing students. Journal of Advanced Nursing, 61(4), 436–444. doi:10.1111/j.1365-2648.2007.04504.x Garnham, P. (2001). Understanding and dealing with anger, aggression and violence. Nursing Standard, 16(6), 37–37–42. Gerberich, S. G., Church, T. R., McGovern, P. M., Hansen, H., Nachreiner, N. M., Geisser, M. S., & Jurek, A. (2005). Risk factors for work-related assaults on nurses. Epidemiology, 16(5), 704–709. Gerdtz, M. F., Daniel, C., Dearie, V., Prematunga, R., Bamert, M., & Duxbury, J. (2013). The outcome of a rapid training program on nurses’ attitudes regarding the prevention of aggression in emergency departments: A multi-site evaluation. International Journal of Nursing Studies, 50(11), 1434–1445. Grenade, K., & Macdonald, E. (1995). Risk of physical assaults among student nurses. Occupational Medicine, 45(5), 256–258. doi:10.1093/occmed/45.5.256
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Hahn, S., Müller, M., Needham, I., Dassen, T., Kok, G., & Halfens, R. J. G. (2010). Factors associated with patient and visitor violence experienced by nurses in general hospitals in Switzerland: a cross-sectional survey. Journal of Clinical Nursing, 19(23–24), 3535–3546. doi:10.1111/j.1365-2702.2010.03361.x Hegney, D., Plank, A., & Parker, V. (2003). Workplace violence in nursing in Queensland, Australia: A selfreported study. International Journal of Nursing Practice, 9(4), 261–268. IBM. (2012). SPSS statistics (version 21). Chicago, IL: Author. Retrieved from www.spss.com International Council of Nurses. (2006). Abuse and violence against nursing personnel. Geneva, Switzerland: Author. Retrieved from http://www.icn.ch/images/ stories/documents/publications/position_statements/ C01_Abuse_Violence_Nsg_Personnel.pdf Kansagra, S. M., Rao, S. R., Sullivan, A. F., Gordon, J. A., Magid, D. J., Kaushal, R., & Blumenthal, D. (2008). A survey of workplace violence across 65 U.S. Emergency Departments. Academic Emergency Medicine, 15(12), 1268–1274. doi:10.1111/j.1553-2712.2008.00282.x Longo, J. (2007). Horizontal violence among n ursing students. Archives of Psychiatric Nursing, 21(3), 177–178. Luck, L., Jackson, D., & Usher, K. (2006). Survival of the fittest, or socially constructed phenomena? Theoretical understandings of aggression and violence towards nurses. Contemporary Nurse, 21(2), 251–263. doi: 10.5172/conu.2006.21.2.251 Maltby, J., Williams, G., McGarry, J., & Day, L. (2010). Research methods for nursing and healthcare. Harlow, England: Pearson Education. McEwan, D., & Dumpel, H. (2012). Workplace violence assessing occupational hazards and identifying strategies for prevention, part 1. National Nurse, 108(1), 18–27. Nachreiner, N. M., Gerberich, S. G., Ryan, A. D., & McGovern, P. M. (2007). Minnesota nurses’ study: perceptions of violence and the work environment. Industrial Health, 45(5), 672–678. Nau, J., Dassen, T., Halfens, R., & Needham, I. (2007). Nursing students experiences in managing patient aggression. Nurse Education Today, 27(8), 933–946. Nau, J., Dassen, T., Needham, I., & Halfens, R. (2009). The development and testing of a training course in aggression for nursing students: A pre-and post-test study. Nurse Education Today, 29(2), 196–207. Nau, J., Halfens, R., Needham, I., & Dassen, T. (2010). Student nurses’ de-escalation of patient aggression: A pretest-posttest intervention study. International Journal of Nursing Studies, 47(6), 699–708.
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Accepted 03 October 2014
N O W AVA I L A B L E Supporting a Strong and Resilient Contemporary Nursing Workforce A special issue of Contemporary Nurse – Volume 45 Issue 1 – 144 Pages – ISBN 978-1-921980-15-2 – August 2013 Editors: Debra Jackson (University of Technology, Sydney, NSW, Australia), Michelle Cleary (National University of Singapore, Singapore) and Sharon Andrew (Anglia Ruskin University, Chelmsford and Cambridge, United Kingdom) Editorial: A reason, a season or a lifetime? The importance of positive collegial relationships and networks in establishing career sustainability and resilience – Debra Jackson, Sharon Andrew and Michelle Cleary Editorial: Building a resilient and sustainable workforce in healthcare: what might it take? – Kim Walker Editorial: Building a resilient and sustainable workforce in aged care – Richard Baldwin Integrative review: Attributes of clinical leadership in contemporary nursing: an integrative review – Judy Mannix, Lesley Wilkes and John Daly Literature review: Finding a way forward: Reviewing the current debates around clinical supervision – Sophie Dilworth, Isabel Higgins, Vicki Parker, Brian Kelly and Jane Turner Continuing professional development in nursing in Australia: Current awareness, practice and future directions – Mary Katsikitis, Margaret McAllister, Rachael Sharman, Lisa Raith, Annette Faithfull-Byrne and Rae Priaulx ‘I thought I was just going to teach’: Stories of new nurse academics on transitioning from sessional teaching to continuing academic positions – Fiona McDermid, Kathleen Peters, John Daly and Debra Jackson Individual-level outcomes from a national clinical leadership development programme – Declan Patton, Gerard M Fealy, Martin S McNamara, Mary Casey, Louise Doyle, Thomas O’Connor and Christina Quinlan Transition to work and the career destinations of double degree nurses – Noelene Hickey, Linda Harrison and Jennifer Sumsion
Debate paper: Primary Health Care as a philosophical and practical framework for nursing education: Rhetoric or reality? – Sandra Mackey, Deborah Hatcher, Brenda Happell and Michelle Cleary The health of nurses aged over 50 in New Zealand – Jill Clendon and Léonie Walker Using appreciative inquiry to transform health care – Suza Trajkovski, Virginia Schmied, Margaret H Vickers and Debra Jackson Literature review: Understanding moral habitability: A framework to enhance the quality of the clinical environment as a workplace – Rebecca Anne Vanderheide, Cheryle Moss and Susan Lee Enhancing the resilience of nurses and midwives: Pilot of a mindfulness based program for increased health, sense of coherence and decreased depression, anxiety and stress – Maralyn Foureur, Karyn Besley, Geraldine Burton, Nicholas Yu and Jackie Crisp A good day in nursing: Views of recent Singaporean graduates – Michelle Cleary, Jan Horsfall PhD, Paulpandi Muthulakshmi and Debra Jackson Personal resilience in nurses and midwives: Effects of a workbased educational intervention – Glenda E McDonald, Debra Jackson, Lesley Wilkes and Margaret H Vickers Book reviews The Resilient Nurse: Empowering Your Practice – Margaret McAllister and John B Lowe (Eds) – Reviewed by Louise D Hickman
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Prevalence and characteristics of aggression and violence experienced by Western Australian nursing students during clinical practice Martin Hopkins, Catherine M Fetherston and Paul Morrison School of Health Professions, Murdoch University, Perth, WA, Australia
Abstract: Aim: To identify the prevalence and characteristics of aggression and violence experienced by undergradu-
ate nursing students in the clinical setting. Method: A cross sectional survey of second (N = 97) and third (N = 56) year nursing students in a Western Australian University was conducted. Data were analysed using frequencies, percentages and means (standard deviation) and independent samples t-test for between group differences. Results: Over 58% (N = 55) of second year and 57% (N = 32) of third year nursing students experienced some kind of non-physical violence. Various forms of physical violence were also reported by over a third (N = 33) of the second year and 25% (N = 18) of the third year nursing students. Conclusion: This study has identified nursing students are exposed to, and feel at significant risk of, aggression and violence in the clinical setting. Providing them with an appropriate level of knowledge and self-confidence to assist in the management of the threat and actuality of such incidents is essential.
Keywords: physical, non-physical, aggression, violence, nursing student, prevalence
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ggression and violence is a significant problem and is witnessed in all aspects of modern society. This is evident in the everyday exposure experienced by people to aggressive and violent incidents via media, such as television, newspapers, radio and games, as well as in their personal lives (Garnham, 2001). There are no borders or boundaries concerning aggression and violence and incidents occur in all countries, cultures, races, ages and contexts. The global increase in violence and aggression is impacting public health systems dramatically (McEwan, 2012; van den Bossche, 2013). This is evidenced in the US healthcare setting, where violence is said to account for 45% of all workplace related incidents (McEwan, 2012), whist in Australia, the health care setting has been identified as the most violent working environment (Perrone, 1999; Pich, Hazelton, Sundin, & Kable, 2010). It is widely accepted that nursing is one of the highest risk jobs for encountering violence and aggression (Gerberich et al., 2005; Pich, Hazelton, Sundin, & Kable, 2011) and staff within the profession are deemed at higher risk of violence and aggression than even police and prison officers (Perrone, 1999). Nurses are four times more likely to experience a violent attack than any other health care worker (Wells & Bowers, 2002) and it has been suggested that at some point in their
careers, all nurses will be involved in a violent or aggressive situation (Yassi, 1994). Research undertaken over the past two decades and in a number of countries, including the UK, Turkey, Germany and Israel (Bronner, Peretz, & Ehrenfeld, 2003; Celik & Bayraktar, 2004; Nau, Dassen, Halfens, & Needham, 2007) shows that nursing students were also being subjected to violence and aggression in the clinical setting and may indeed be at higher risk of exposure than other healthcare workers. However no studies have investigated the prevalence and types of violence and aggression being experienced by nursing students in Australia. This knowledge is essential if we are to appropriately prepare our nursing students to deal with these adverse incidents. There are many forms of aggression and violence and consequently there is much debate in the literature as to what constitutes an appropriate definition. The terms aggression and violence are subjective in nature and this therefore, adds to the difficulties associated with assigning a specific definition to encompass the spectrum of behaviours by which it is represented (Hegney, Plank, & Parker, 2003). In an attempt to provide a comprehensive operational definition for the study, minimise confusion on the part of participants and reduce the subjectivity associated with the terminology, workplace aggression and violence was
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divided into physical and non-physical elements, as defined by the Western Australian Department of Health (2004) (Figure 1). Objectives of this study The results presented here are part of a larger study that compared two previously untested paedagogies designed to build resilience and increase positivity in nursing students when encountering aggression and violence in the clinical setting. As part of this study one of the objectives was to investigate the prevalence and characteristics of aggression and violence experienced by undergraduate nursing students in a Western Australian university during exposure to workplace learning.
The third year nursing students had attended at least four clinical practicums, including mental health and acute care placements. No exclusion criterion was invoked and students had the right to refuse to participate.
Methodology A cross sectional survey was used to collect demographic and descriptive data on prevalence and nursing student’s experiences of violence and aggression in the clinical setting. Demographic data collected included participant’s age, gender, marital status, combined annual household income, hours of paid employment per week and number of children. Participants were also asked to rate their perceived level of risk of physical and non-physical Sample This study used purposive sampling with the aggression and violence and then indicate if they sample frame consisting of all second and third had ever experienced any physical or non-physical year undergraduate nursing students enrolled in a aggression and violence during placements. The core nursing unit in a 3-year Bachelor of Nursing rating scale responses on the 1–5 scale for level of Program at a Western Australian metropolitan risk were 1 = never to 5 = all of the time. Specific University in semester one, 2013. The second year questions regarding experiences with violence and students had only experienced two clinical prac- aggression included frequency of incidents, time tice placements prior to completion of the survey, since last incident, perpetrator, form of aggression both of which were in the aged care environment. and violence, any injury sustained and if any time off work was required as a result of the incident. All information Workplace aggressive behaviour: incidents, perceived or real to individuals, when sought was within the context of the participant’s workplace they are abused, threatened or assaulted in circumstances arising out of, or in the experience as a nursing student course of their employment, involving an explicit or implicit challenge to their and no information was gathered safety, health or wellbeing. relating to personal experiences outside this context. Workplace violence: an action or incident that physically or psychologically harms Prior to the data collection another person. It includes situations where employees and other people are phase of the study the questhreatened, attacked or physically assaulted at work. tionnaire was pilot tested with a group of third year nursNon-physical violence such as verbal abuse, intimidation and threatening ing students for face validbehaviour, may also significantly affect a person’s health and wellbeing. Threats ity and appropriateness of the may be perceived or real and there does not have to be physical injury for the questions (Maltby, Williams, McGarry, & Day, 2010). The violence to be a workplace hazard. Employees may be affected by workplace questionnaire was also tested violence even if they are not directly involved. for face validity by six of the Department of Health Prevention of Workplace Aggression and Violence Policy and Guidelines (2004) authors’ professional colleagues with backgrounds in emergency care, aged care, mental health care and midwifery. Items for Figure 1: Definition of aggression and violence 114
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Prevalence and characteristics of aggression and violence experienced inclusion in the questionnaire were drawn from the literature and focussed on helping to answer some of the primary research questions. Analysis was conducted using PASW, SPSS Statistics version 21 for Windows (IBM, 2012) with descriptive data reporting frequencies, percentages and either median and interquartile range or mean and standard deviation (SD) according to normality. Independent samples t-test was used to compare between groups differences. All p levels lower than 0.05 were considered significant. Approval for the study was granted by Murdoch University Human Research Ethics Committee (2012/126).
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Demographic characteristics Participants were predominantly female with a broad range of ages from 17 to 54 years (mean 29.8), with the majority under 45 years and without children. Annual family income did differ between year groups with more third year than second year students reporting an income over $100,000 although this was not statistically significant (p = 0.407). Approximately a quarter of third year students and a third of second year students earned 44 years stabbing (Table 2). Almost Annual family income (AFI) all of the instances of physi37.2% (N = 35) 29.4% (N = 15) $100,000 rarely felt at risk of physical Number of children violence with the remaining 0 48.9% (N = 46) 53.7% (N = 29) 45% feeling at risk either 1 4.3% (N = 4) 9.3% (N = 5) sometimes, often, or all the 2 24.5% (N = 23) 16.7% (N = 9) time (Table 3). Similarly 3 14.9% (N = 14) 9.3% (N = 5) nearly 60% of third year stu 4 3.2% (N = 3) 7.4% (N = 4) dents said they either never 4.4% (N = 4) 3.7% (N = 2) >4 or rarely felt at risk of physiHours of paid employment 9.62 ± 9.93* 11.70 ± 11.40* cal violence in the workplace *Mean and SD. with the remaining 40%
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violence during clinical practice with all of the students experiencing non-physical aggression Type of physical Second year Third year and violence more than once aggression experienced students (N = 97) students (N = 56) (Table 4). The perpetrator was Grabbed 30.3% (N = 10) 27.8% (N = 5) predominantly the patient but Pushed 3% (N = 1) 5.6% (N = 1) other healthcare workers were Bitten 6.1% (N = 2) Nil also identified (Table 4). Just Punch/attempted punch 36.4% (N = 12) 50% (N = 9) under half the students reported Object thrown 9.1% (N = 3) 5.6% (N = 1) that they either never or rarely felt Slap Nil 5.6% (N = 1) at risk of non-physical violence Kicked Nil 5.6% (N = 1) whereas 58% felt at risk either Attempted stabbing 3% (N = 1) Nil sometimes, often or all the time 34% (N = 33) 32.7% (N = 18) Total reporting any form (Table 5). of physical aggression A similar number and type of and violence the non-physical incidents expePerpetrator rienced by second years were Patient Colleague 97% (N = 32) 88.9% (N = 16) also reported by third years with Registered nurse 3% (N = 1) 11.1% (N = 2) 57% having experienced nonphysical violence. Sixty three percent were exposed to such Table 3: Perceived risk of physical aggression and violence an incident on more than one of student participants (N = 152) occasion (Table 4). Only a third Level of perceived risk Second year Third year stated that they either never or of physical aggression students (N = 97) students (N = 55) rarely felt at risk of non-physical and violence violence whereas 66% felt at risk either sometimes, often or all the Never 9.3% (N = 9) 20% (N = 11) time (Table 5) with 71% of inciRarely 45.4% (N = 44) 38.2% (N = 21) dents occurring within the last Sometimes 35.1% (N = 34) 34.5% (N = 19) 12 months. The third year stuOften 8.2% (N = 8) 5.5% (N = 3) dents reported similar perpetraAll the time 2.1% (N = 2) 1.8% (N = 1) tors to the second year students although there was a slightly feeling at risk either sometimes, often or all the increased incidence of healthcare workers identime. Actual physical violence was reported by tified (Table 4). 25% of students, of whom more than half expeIt was reported by both third year and second rienced the abuse in the last 12 months, with the year students that, as a direct result of the effects patient being the main perpetrator (Table 2). of the non-physical aggression and violence, time The physical violence experienced by the stu- off work was required. dents resulted in four of the second year students and two of the third year students sustaining an Discussion injury. These injuries resulted in five of the stu- The prevalence and characteristics of aggression dents requiring time off work. The type of injury and violence affecting Australian nursing students was not specified. in the workplace is reported in this paper for the first time, and indicates there is significant cause for concern. It is clear from this study’s findings Non-physical violence and aggression Just over 58% of the second year nursing students that a significant number of nursing students are reported a history of experiencing non-physical affected by workplace aggression and violence, Table 2: Type of physical aggression incidents (N = 51) experienced by year of student
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Prevalence and characteristics of aggression and violence experienced
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and violence’. This study sought to ensure a comprehensive definition encompassing both physical and non-physical aggression (Figure 1) to Second year Third year Frequency of nonstudents students physical aggression guide the participants in their survey (N = 48) (N = 30) and violence answers. This allows for greater accuracy and reproducibility of findings One occasion Nil 36.7% (N = 11) and provides the potential for a betGreater one occasion 100% (N = 48) 63.3% (N = 19) ter understanding of the scale of the Number of incidents 6.19 ± 16.08* 6.30 ± 10.28* problem to which nursing students 58.5% (N = 55) 57.1% (N = 32) Total reporting any are exposed. non-physical aggression The findings from this current study, and violence Third year Second year Perpetrator of nonin relation to the prevalence of physical students students physical aggression violence and aggression, are supported (N = 33**) (N = 54) and violence by a similar, although less recent, Patient 85.2% (N = 46) 60.6% (N = 20) report from the US of registered nurses Patients relative 3.7% (N = 2) 9.1% (N = 3) (Nachreiner, Gerberich, Ryan, & Registered nurse 3.7% (N = 2) 18.2% (N = 6) McGovern, 2007). As expected prevaCare assistant 5.6% (N = 3) 9.1% (N = 3) lence amongst registered nurses has Colleague 1.9% (N = 1) Nil been reported as even higher in more Clinical educator Nil 3% (N = 1) recent studies and ranges from 42% *Mean and SD; **some students reported more than one perpetrator. in Switzerland (Hahn et al., 2010) to 81% in Turkey (Erkol, Gokdogan, Table 5: Perceived risk of non-physical aggression and violence Erkol, & Boz, 2007). of student participants (N = 153) The consequences of physical violence in the healthcare environSecond year Third year Level of perceived risk of ment is often the focus of aggression students students non-physical aggression (N = 97) (N = 56) and violence and violence studies (Kansagra et al., 2008; Paterson, Leadbetter, & Bowie, Never 6.2% (N = 6) 8.9% (N = 5) 2001), however, the prevalence of Rarely 36.1% (N = 35) 25% (N = 14) non-physical aggression and vioSometimes 43.3% (N = 42) 46.4% (N = 26) lence reported in this study exceeded Often 12.4% (N = 12) 17.9% (N = 10) physical forms by over 20%. These All the time 2.1% (N = 2) 1.8% (N = 1) findings are supported in the general aggression and violence literawith similar levels reported as those previously ture (Camerino, Estryn-Behar, Conway, van Der experienced by registered nurses and other health Heijden, & Hasselhorn, 2008; Pich et al., 2011; care workers in the United Kingdom (Grenade & Wells & Bowers, 2002) and the literature that Macdonald, 1995; Winstanley & Whittington, specifically addresses the issue amongst the nurs2004). The high levels of aggression and violence ing student population (Celik & Bayraktar, 2004; reported in this study has the potential to nega- Ferns & Meerabeau, 2008). The finding that over tively impact students’ physical and psychologi- half the students surveyed reported experiences of cal health, as well as impact workforce retention non-physical aggression is similar to findings in in the future. It is difficult to understand the full Turkey, Germany and Israel (Bronner et al., 2003; extent of the prevalence of aggression and vio- Celik & Bayraktar, 2004; Nau et al., 2007), with lence nurses and nursing students are exposed to the study from Turkey reporting that all students due to the participant subjectivity and potential surveyed had experienced some verbal aggression multiple interpretations of the term ‘aggression (Celik & Bayraktar, 2004). Table 4: Frequency of non-physical aggression and violence experienced by student participants including type of perpetrator (N = 87)
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A second and more recent study from Turkey also confirmed that the problem is continuing and found that over 90% of nursing students subjected to violence (N = 175) had experienced verbal abuse, with patients being the main perpetrators (Çelebioglu, Akpinar, Küçükoglu, & Engin, 2010). What has not been reported so far in the literature, that was evident in this current study, is how at risk of non-physical aggression and violence many nursing students feel. This feeling of risk has the potential to negatively impact their confidence, health and everyday functioning and is an issue that requires immediate attention. A key strategy outlined in the literature that is designed to tackle the problem of workplace aggression and violence is that of education, however, this is predominantly in the postgraduate environment. Most often this education focuses on the use of de-escalation, breakaway and restraint techniques (Rintoul, Wynaden, & McGowan, 2009; Wand & Coulson, 2006), although a recent Australian study attempted to modify staff attitudes towards prevention of violence through education, with limited success (Gerdtz et al., 2013). Education specifically targetted for nursing students in the UK and Germany has been reported (Beech, 2001; Beech & Leather, 2003; Nau, Dassen, Needham, & Halfens, 2009; Nau, Halfens, Needham, & Dassen, 2010). Both studies provided the nursing students with a stand-alone three day course, however, the UK study focussed on communication techniques and personal safety whereas the study by Nau et al. (2009) addressed levels of student coping. Post course analysis provided evidence of increased student awareness and ability to cope with aggression and violence and confidence in dealing with situations. However, reports of the integration of aggression and violence education into an undergraduate curriculum still do not exist. This indicates a need for undergraduate aggression and violence education to be integrated into the nursing curriculum to better prepare nursing students when faced with aggressive and violent incidents in the clinical setting. Perpetrators of both physical and nonphysical violent incidents were predominantly identified in this current study as the patient, 118
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which is similar to previous studies (Nachreiner et al., 2007; Pich et al., 2011), although some of the students in this current study identified registered nurses and colleagues as the perpetrator. Authors reporting on bullying in the nursing profession (Longo, 2007; Rowe, 2005) have previously commented that nurses have a tendency to ‘eat their young’. However this generalisation was not reflected in the comparatively small numbers of aggressive and violent incidents experienced by the students at the hands of registered nurses. The International Council of Nurses (2006) called for zero tolerance an all forms of aggression and violence, therefore, despite the small numbers involved in this form of incident in this study, no level of physical or non-physical aggression or violence is acceptable, and that acts of aggression and violence perpetrated by those who hold positions of power over vulnerable students are particularly disturbing. Data from this study indicates the length of time spent as a nursing student does not increase the prevalence of physical violence as approximately equal numbers of both second year and third year students reported physical violence since commencing their studies. The second year students surveyed had only been engaged in aged care work placements, supporting the notion that the general ward area, and particularly aged care, is a high risk environment for aggression and violence (Whittington, 1996; Winstanley & Whittington, 2004). Indeed, aged care and nursing home facilities have been identified as areas of significant risk of aggression and violence in the US (Gerberich et al., 2005) and Australia (Hegney et al., 2003). This source of aggression and violence that nursing students are exposed to requires further research. The forms of abuse reported, such as punching and grabbing, were also similar between year groups however one second year student reported an attempting stabbing occurring within the aged care setting, which is of particular concern due to the potential for serious injury and even death. Some of the incidents had a significant negative impact on the students with some requiring time off work due to physical violence (N = 7) and non-physical violence (N = 4). Any reports of aggression and violence are of concern; however, reports of nursing students requiring time
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Prevalence and characteristics of aggression and violence experienced off work clearly have health and economic implications that require addressing. Due to the level and severity of the aggression and violence student nurses are being exposed to it is evident that they require preparation to cope with these events before entering the clinical environment. It is suggested on the basis of the findings from this study that there be a paradigm shift to bring aggression and violence education into the undergraduate curriculum to specifically target the issues experienced by nursing students. Limitations The findings are limited by the setting and generalisability may be problematic within Australia due to variations in the structure of nursing programmes offered at other Australian Universities, particularly where students may attend different clinical placements at different stages of their programmes. However, the authors are confident this limitation was minimised as both second and third year students were surveyed and breadth of clinical experience within nursing programmes in Australia is standardised through accreditation by the Australia Nursing and Midwifery Accreditation Council. Generalisability may also be limited due to the small sample of nursing students drawn from one University and self-selection by students who had experienced aggression and violence could not be ruled out. Self-report data provided may limit the reliability of some responses, including in relation to recall of the frequency of exposure to violence and aggression, and no attribution of causality can be made. Although a definition of workplace violence and aggression was provided in each section of the survey instrument to guide the participants and assist reliability and validity of the data collected, survey responses were nonetheless subject to students’ own perceptions of workplace violence and aggression. The authors sought to minimise such subjectivity through careful selection of a definition chosen to enhance clarity regarding the varying forms of aggression and violence (Chapman & Styles, 2006; Farrell, Shafiei, & Chan, 2013; Luck, Jackson, & Usher, 2006). Conclusion and recommendations This study has identified student nurses are exposed to significant levels of aggression and © eContent Management Pty Ltd
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violence and often feel at risk of aggression and violence in the clinical setting. Clearly action needs to be taken to protect the students and to better prepare them at an undergraduate level to confront these experiences of aggression and violence. This will enable nursing students to enter the clinical setting prepared for potential aggressive and violent events. This study has identified the extent and nature of the problems related to violence and aggression that nursing students are facing and it is recommended that further research be conducted to introduce reporting and support systems involving both placement sites and universities. The aim of introducing reporting systems should be focussed on instigating an investigative process that will have the potential to activate interventions in both the clinical and education environments to aid in supporting and protecting the nursing students. Additionally collaborative, longitudinal studies are required that address the shortfalls in undergraduate aggression and violence training to enable nursing students to deal with these situations and to build resilience to aggression and violence through appropriate education. If targetted correctly, universities have the potential to better prepare nursing students to respond confidently, positively and capably to any violence and aggression encountered in the workplace. Acknowledgements The authors would like to thank the nursing students who participated in this study for their time and effort in completing the surveys. The authors would also like to acknowledge the efforts of the lecturing staff, for providing the time and opportunity for the surveys to be carried out within their units. References
Beech, B. (2001). Sign of the times or the shape of things to come? A 3-day unit of instruction on ‘aggression and violence in health settings for all students during pre-registration nurse training’. Accident and Emergency Nursing, 9(3), 204–211. Beech, B., & Leather, P. (2003). Evaluating a management of aggression unit for student nurses. Journal of Advanced Nursing, 44(6), 603–612.
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Bronner, G., Peretz, C., & Ehrenfeld, M. (2003). Sexual harassment of nurses and nursing students. Journal of Advanced Nursing, 42(6), 637–644. Camerino, D., Estryn-Behar, M., Conway, P. M., van Der Heijden, B. I. J. M., & Hasselhorn, H.-M. (2008). Work-related factors and violence among nursing staff in the European NEXT study: a longitudinal cohort study. International Journal of Nursing Studies, 45(1), 35–50. Çelebioglu, A., Akpinar, R. B., Küçükoglu, S., & Engin, R. (2010). Violence experienced by Turkish nursing students in clinical settings: Their emotions and behaviors. Nurse Education Today, 30(7), 687–691. Celik, S. S., & Bayraktar, N. (2004). A study of nursing student abuse in Turkey. Journal of Nursing Education, 43(7), 330–336. Chapman, R., & Styles, I. (2006). An epidemic of abuse and violence: Nurse on the front line. Accident and Emergency Nursing, 14(4), 245–249. Department of Health. (2004). Prevention of workplace aggression and violence policy and guidelines. Perth, WA: Government of Western Australia. Retrieved from http://www.nursing.health.wa.gov.au/docs/ reports/WorkplaceAggression_Violence.pdf Erkol, H., Gokdogan, M. R., Erkol, Z., & Boz, B. (2007). Aggression and violence towards health care providers – A problem in Turkey? Journal of Forensic and Legal Medicine, 14(7), 423–428. Farrell, G. A., Shafiei, T., & Chan, S. P. (2013). Patient and visitor assault on nurses and midwives: An exploratory study of employer ‘protective’ factors. International Journal of Mental Health Nursing, 23(1), 88–96. Ferns, T., & Meerabeau, L. (2008). Verbal abuse experienced by nursing students. Journal of Advanced Nursing, 61(4), 436–444. doi:10.1111/j.1365-2648.2007.04504.x Garnham, P. (2001). Understanding and dealing with anger, aggression and violence. Nursing Standard, 16(6), 37–37–42. Gerberich, S. G., Church, T. R., McGovern, P. M., Hansen, H., Nachreiner, N. M., Geisser, M. S., & Jurek, A. (2005). Risk factors for work-related assaults on nurses. Epidemiology, 16(5), 704–709. Gerdtz, M. F., Daniel, C., Dearie, V., Prematunga, R., Bamert, M., & Duxbury, J. (2013). The outcome of a rapid training program on nurses’ attitudes regarding the prevention of aggression in emergency departments: A multi-site evaluation. International Journal of Nursing Studies, 50(11), 1434–1445. Grenade, K., & Macdonald, E. (1995). Risk of physical assaults among student nurses. Occupational Medicine, 45(5), 256–258. doi:10.1093/occmed/45.5.256
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Accepted 03 October 2014
N O W AVA I L A B L E Supporting a Strong and Resilient Contemporary Nursing Workforce A special issue of Contemporary Nurse – Volume 45 Issue 1 – 144 Pages – ISBN 978-1-921980-15-2 – August 2013 Editors: Debra Jackson (University of Technology, Sydney, NSW, Australia), Michelle Cleary (National University of Singapore, Singapore) and Sharon Andrew (Anglia Ruskin University, Chelmsford and Cambridge, United Kingdom) Editorial: A reason, a season or a lifetime? The importance of positive collegial relationships and networks in establishing career sustainability and resilience – Debra Jackson, Sharon Andrew and Michelle Cleary Editorial: Building a resilient and sustainable workforce in healthcare: what might it take? – Kim Walker Editorial: Building a resilient and sustainable workforce in aged care – Richard Baldwin Integrative review: Attributes of clinical leadership in contemporary nursing: an integrative review – Judy Mannix, Lesley Wilkes and John Daly Literature review: Finding a way forward: Reviewing the current debates around clinical supervision – Sophie Dilworth, Isabel Higgins, Vicki Parker, Brian Kelly and Jane Turner Continuing professional development in nursing in Australia: Current awareness, practice and future directions – Mary Katsikitis, Margaret McAllister, Rachael Sharman, Lisa Raith, Annette Faithfull-Byrne and Rae Priaulx ‘I thought I was just going to teach’: Stories of new nurse academics on transitioning from sessional teaching to continuing academic positions – Fiona McDermid, Kathleen Peters, John Daly and Debra Jackson Individual-level outcomes from a national clinical leadership development programme – Declan Patton, Gerard M Fealy, Martin S McNamara, Mary Casey, Louise Doyle, Thomas O’Connor and Christina Quinlan Transition to work and the career destinations of double degree nurses – Noelene Hickey, Linda Harrison and Jennifer Sumsion
Debate paper: Primary Health Care as a philosophical and practical framework for nursing education: Rhetoric or reality? – Sandra Mackey, Deborah Hatcher, Brenda Happell and Michelle Cleary The health of nurses aged over 50 in New Zealand – Jill Clendon and Léonie Walker Using appreciative inquiry to transform health care – Suza Trajkovski, Virginia Schmied, Margaret H Vickers and Debra Jackson Literature review: Understanding moral habitability: A framework to enhance the quality of the clinical environment as a workplace – Rebecca Anne Vanderheide, Cheryle Moss and Susan Lee Enhancing the resilience of nurses and midwives: Pilot of a mindfulness based program for increased health, sense of coherence and decreased depression, anxiety and stress – Maralyn Foureur, Karyn Besley, Geraldine Burton, Nicholas Yu and Jackie Crisp A good day in nursing: Views of recent Singaporean graduates – Michelle Cleary, Jan Horsfall PhD, Paulpandi Muthulakshmi and Debra Jackson Personal resilience in nurses and midwives: Effects of a workbased educational intervention – Glenda E McDonald, Debra Jackson, Lesley Wilkes and Margaret H Vickers Book reviews The Resilient Nurse: Empowering Your Practice – Margaret McAllister and John B Lowe (Eds) – Reviewed by Louise D Hickman
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