ORIGINAL ARTICLE

Workplace violence against clinicians in Cypriot emergency departments: a national questionnaire survey Paraskevas Vezyridis, Alexis Samoutis and Petroula M Mavrikiou

Aims and objectives. To identify perceived prevalence, characteristics, precipitating factors and suggestions for improving workplace violence in all nine public emergency departments in the Cyprus Republic. Background. Workplace violence is a common phenomenon in emergency departments, but little is known about this phenomenon in Cyprus. Design. A retrospective cross-sectional survey. Methods. Two hundred and twenty of 365 emergency nurses (85
7%) and doctors (14
3%) participated in this study, of which 62% were female. Data were collected via a Greek language version of the Violent Incident Form. Additional questions examined perceived frequencies, encouragement for reporting, satisfaction with actions taken and suggestions for improvement. Descriptive analysis, chi-square tests and multiple logistic regression analyses were used to describe and associate characteristics with workplace prevalence. Results. During the previous 12 months, the vast majority of nurses and doctors (76
2%) were exposed to verbal abuse (88
8%), mainly by relatives or friends of the patient (59
1%). Relatively inexperienced clinicians were at greater risk. Waiting time was identified as the most significant organisational factor. Alcohol intoxication, substance abuse and mental illness were individual factors for workplace violence. Severe underreporting (72
2%) and a belief that workplace violence is part of the work (74
1%) were also identified. Workplace violence was highly correlated with several factors, including a lack of encouragement for reporting, a feeling in advance that a violent incident was about to happen and having to handle the incident personally. Suggestions for improvement included more security measures (26
7%) and public education about the proper use of emergency services (15
2%). Conclusion. Verbal abuse is common in Cypriot emergency departments, but clinicians are increasingly worried about physical assaults. Relevance to clinical practice. Training, security policies, encouragement of reporting and support for staff after a violent incident are needed. Future research should try to include the perpetrator’s viewpoint.

Authors: Paraskevas Vezyridis, PhD, Lecturer, School of Health Sciences, Frederick University Cyprus, Nicosia; Alexis Samoutis, PhD, Lecturer, School of Health Sciences, Frederick University Cyprus, Nicosia; Petroula M Mavrikiou, PhD, Assistant Professor, School of Economic Sciences and Administration, Frederick University Cyprus, Nicosia, Cyprus

© 2014 John Wiley & Sons Ltd Journal of Clinical Nursing, doi: 10.1111/jocn.12660

What does this paper contribute to the wider global clinical community?

• Relatively inexperienced emer-

•

•

gency department clinicians are at greater risk of experiencing workplace violence, but in general, ED staff are increasingly worried about physical assaults. Workplace violence is highly correlated with a lack of encouragement for reporting, a feeling in advance that a violent incident is about to occur and having to handle the incident personally, as well as anger and stress. Emergency department clinicians suggest that more security measures and public education about the appropriate use of emergency department are needed.

Correspondence: Paraskevas Vezyridis, Lecturer, School of Health Sciences, Frederick University Cyprus, 7 Y. Frederickou Str., Nicosia 1036, Cyprus. Telephone: +357 22431355. E-mail: [email protected]

1

P Vezyridis et al.

Key words: Cyprus, emergency department, health professionals, patient, survey, workplace violence Accepted for publication: 16 June 2014

Introduction and background The public healthcare sector is among the most aggressive and violent workplaces (Perrone 1999). In fact, it is more violent by factor of 4 when compared to the private sector (National Institute of Occupational Safety and Health [NIOSH] & Centers for Disease Control and Prevention [CDC] 2002). Nurses in particular are a high risk group for experiencing the results of violent behaviour by patients and their relatives or friends (Carter 2000, Pai & Lee 2011, Magnavita & Heponiemi 2012). This phenomenon is on the increase (Hegney et al. 2006, Hilliar 2008). This has prompted the International Council of Nurses (ICN) to condemn the abuse of nurses in their workplace (ICN 1999, Buchan & Calman 2005). One particular hospital department affected is the emergency department (ED). For nurses (Gates et al. 2006), EDs are a high risk setting for experiencing violence and aggression (May & Grubbs 2002, Crilly et al. 2004, Gerberich et al. 2004, Winstanley & Whittington 2004). This occupational health and safety issue has become so ingrained that in some EDs, nurses experience violence on a weekly basis (Lyneham 2000), placing the ED on top of the list of the most violent hospital departments (Gerberich et al. 2004, Magnavita & Heponiemi 2012). Although an agreed definition of workplace violence (WPV) has yet to be found (Taylor & Rew 2011), it has been defined as ‘..an act that includes physical force such as slapping, punching, kicking and biting; use of an object as a weapon; aggressive behaviour such as spitting, scratching and pinching; or a verbal threat involving no physical contact’ (Nolan et al. 2001, p. 421). The European Commission defines WPV as ‘Incidents where staff are abused, threatened or assaulted in circumstances related to their work, including commuting to and from work, involving an explicit or implicit challenge to their safety, well-being or health’ (International Labour Office/International Council of Nurses/World Health Organization/Public Services International 2002, p. 3). No matter what definition is used to understand and examine violence in the ED, there is no doubt that its consequences can be severe for everyone involved. Apart from the actual physical injury, WPV in EDs may lead clinicians to experience additional job-related stress and burnout (Crabbe et al. 2004), feelings of vulnerability (Catlette

2

2005, Gates et al. 2006), fear (Lyneham 2000, Kowalenko et al. 2005) and self-blame (Sßenuzun Erg€ un & Karadakovan 2005) as well as decreased job satisfaction (Fernandes et al. 1999, Gates et al. 2006). This situation contributes to the growing problem of ED staff turnover and retention (Fernandes et al. 1999). Moreover, a growing literature is showing emotional and cognitive consequences of the violent incident (Gates et al. 2011), leading to poor quality care (Pich et al. 2010). These include medication errors, poor clinical decision-making and delays in assessment and treatment (Gillespie 2008). Unfortunately, underreporting of WPV has also been documented (Jenkins et al. 1998, Gates et al. 2006). The ICN estimates the magnitude of underreporting to be in the order of 20% (ICN 1999). There are many reasons for violence against ED clinicians going unreported. For example, staff often have the belief that little would be done following making a report (Lyneham 2000, Sßenuzun Erg€ un & Karadakovan 2005). Insufficient time, lack of support, fear of reprimand and a lack of knowledge of the reporting procedure have also been highlighted in the literature as reasons for underreporting (Pich et al. 2010). The consequences of this strengthens a widespread belief that aggression and violence are part of the job description (Jenkins et al. 1998, Lyneham 2000, Ryan & Maguire 2006). It hinders accurate measurement of the magnitude of this phenomenon (Ryan & Maguire 2006) and thus the development of appropriate interventions. The purpose of this study was to describe the phenomenon of workplace violence as experienced by ED clinicians in the Republic of Cyprus. The specific aims were to identify the perceived prevalence and characteristics of violent incidents, precipitating factors and staff suggestions for minimising future occurrences. To our knowledge, there is no prior study of aggression or violence against ED clinicians in the Republic of Cyprus.

Methods Design, setting and population A retrospective cross-sectional survey was conducted for four months between November 2012–February 2013. An anonymous, self-administered questionnaire was distributed © 2014 John Wiley & Sons Ltd Journal of Clinical Nursing

Original article

to all nurses and doctors (n = 365) registered and working in the nine public EDs (five urban, four rural) of the Republic of Cyprus. A census design was employed, and the questionnaires were addressed to all EDs under study. The ED located in the capital city of Nicosia is the largest and busiest ED in the country with around 350 attendances per day (128,000 per year) from a local population of 327,000 (39% of the total population). There are 72 registered nurses and 20 doctors working in this ED. In the smallest rural ED, there are currently four nurses and two doctors.

Data collection All nursing heads of the EDs were personally contacted about the study. Each ED received a ballot box and a number of questionnaires appropriate to their size. Each questionnaire had an information letter, with all the study, ethical and contact details, that participants could keep. The questionnaires were completed during participants’ free time. They were be placed in sealed envelopes and put in the ballot box. At the end of the four-month period, all the ballot boxes were collected.

Questionnaire A Greek version of the Violent Incident Form (VIF) was used to investigate the characteristics of incidents of WPV. The English version of this validated questionnaire was originally developed by Arnetz (1998) and has been used in previous work (Arnetz & Arnetz 2000, Magnavita & Heponiemi 2012). It consists of 14 main items including: • The time and place of the violent incident (waiting room, examination room, corridor, etc.). • Characteristics of the aggressors (gender, age). • Whether it was a patient, relative or member of staff. • Precipitating conditions (alcohol, narcotics, medications, mental illness). • The actual assault (types of verbal or physical violence). • Other action taken during the assault (individual action, help from colleagues). • Injuries and emotions for the victim (e.g. anxiety, anger, fear, humiliation). The word-for-word translation of the English VIF into Greek and back into English (double translation) was completed by the three researchers. The translations were then reviewed and commented on by two professors of nursing. After corrections were agreed and completed, the final version of the questionnaire was pilot tested by a purposive sample of four clinicians working in an ED. These © 2014 John Wiley & Sons Ltd Journal of Clinical Nursing

Workplace violence in Cypriot EDs

participants commented on the wording and the clarity of each question. Their minor corrections were incorporated into the questionnaire. Age, gender and work experience were also collected. Additional questions were added to the original questionnaire to collect: • More information about the perceived frequency of these incidents (via a five-point Likert scale). • Whether incident reporting procedures are in place at the healthcare organisation and whether ED clinicians are encouraged to report such incidents. • Whether leave of absence was taken after the incident, the victim’s level of satisfaction about the actions taken by management (five-point Likert scale). • Suggestions on how to effectively address the phenomenon. Most of these questions also appear in the Workplace Violence Questionnaire (WVQ) (ILO, ICN, WHO, PSI 2003).

Data analysis Data analysis was conducted using SPSS version 19 (IBM Corp. 2011). Due to the small-size sample, descriptive analysis was used for describing demographic data and other categorical variables. Chi-square tests and multivariate analysis (multiple logistic regressions) were conducted to determine which characteristics of the respondents the EDs and the aggressor were associated with the prevalence of ED violent incidents. The descriptive analysis includes absolute values and percentages for the main demographic characteristics. A chi-square test of independence was used to check whether certain characteristics or consequences are associated with the experience of violence. Finally, logistic regression was used to predict a binary outcome. The binary dependent variable under investigation describes the prevalence of ED violence for at least once during the past 12 months (0: no violence; 1: at least one incident of violence during the past 12 months).

Ethical considerations Confidentiality and anonymity were guaranteed in an accompanying letter which also included contact details of the principal researcher (PV). The return of the questionnaire implied consent. Ethics approvals for the study were obtained from the Cyprus National Bioethics Committee (ref. 2012.01.58), the Ministry of Health (ref. 5.34.01.7.6E) and the Office of the Commissioner for Personal Data Protection (ref. 3.28.71).

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P Vezyridis et al. Table 2 Perceived prevalence of workplace violence in the last 12 months by form

Results In total, 220 questionnaires were returned and the overall response rate was 60
27%. The sample consisted of 180 nurses (response rate, 64
77%), 30 doctors (response rate, 36
93%) and 10 individuals who did not disclose their occupation. Table 1 displays the demographic and occupational characteristics of the staff included in the final analysis. Most of the participants were in their 30s (35%), female (62%) and with more than five years work experience (66
8%).

Verbal

Physical

Sexual

Number

n

%

n

%

n

%

1 2–4 5–10 Monthly Weekly Daily No experience Total

24 36 22 34 10 35 59 220

10
9 16
4 10
0 15
5 4
5 15
9 26
8

42 16 2 1 0 1 158 220

19
1 7
3 0
9 0
5 0
0 0
5 71
7

32 5 1 2 0 1 179 220

14
5 2
3 0
5 0
9 0 0
5 81
3

Perceived prevalence of workplace violence The majority of participants (76
2%) indicated that they had experienced workplace violence during the past 12 months, with 15
9% reporting verbal abuse daily, 19
1% reporting at least one incident of physical violence and 14
5% reporting at least one incident of sexual harassment. Table 2 presents the prevalence of WPV by type and frequency. It is worth noting that a large number of clinicians did not report physical attack (71
7%) or sexual harassment (81
3%). Table 1 Demographic and occupational characteristics n Occupation Doctor 30 Nurse 180 Gender Female 81 Male 132 Age (years) 18–29 71 30–39 75 40–49 37 50–59 30 ≥60 1 Work experience (years) 20 40 Colleagues present at least 50% of work time 0 2 1–5 96 6–10 65 11–15 23 >15 20

%*

14
3 85
7 38 62 33
2 35 17
3 14 0
5 1
9 31
3 27
1 11
2 9
8 18
7 0
97 46
60 31
55 11
17 9
71

*Non responses are excluded from the computations of percentages.

4

The violent incident and its consequences The majority of violent incidents (Table 3) occurred on either Friday (20
95%) or Saturday (35
24%), between 21:00–06:00 (50%) and within the wider ED assessment and treatment areas (74
04%), such as the emergency room (28
18%), the triage room (23
76%) and the cubicles (22
1%). Most of the participants (72%) said that there were no other people around at the time of the incident, despite the fact that most of them work with other colleagues present for at least 50% of the time (Table 1). The vast majority of the incidents (Table 4) involved verbal abuse (88
8%), and they were handled solely by the victim (58
7%). Consequences included anger (59
7%), disappointment (34
7%), stress (27
6%), fear (15
3%), humiliation (13
8%), irritation (8
7%), physical injury (2%), incompetence (1%) or guilt (1%). The vast majority of participants (82
9%) indicated that the incident did not result in them taking a leave of absence from work, and they considered the violent incident to be typical of working in the ED (74
1%), although 51
9% believed that it could had been prevented. All percentages calculated in Table 4 are based on the total number of respondents who participated in this question, that is, 196.

Characteristics of perpetrators Table 5 shows the characteristics of perpetrators. The participants described perpetrators as mainly males (80
6%), more than 30 years (62
6%) and being a relative or friend of the patient (59
1%). None of the perpetrators were identified as being under the influence of prescribed medication although 17
9% were thought to be under the influence of alcohol. However, most of the participants either ‘did not know’ (33
7%) or chose ‘none of the above’ (35
2%). © 2014 John Wiley & Sons Ltd Journal of Clinical Nursing

Original article

Workplace violence in Cypriot EDs

Table 3 Day, time and location of the violent incident n Day Monday Tuesday Wednesday Thursday Friday Saturday Sunday Time 00–03 03–06 06–09 09–12 12–15 15–18 18–21 21–24 Location Emergency room Triage Cubicle Corridor Waiting area Other

%*

10 6 13 13 22 37 4

9
52 5
71 12
38 12
38 20
95 35
24 3
82

25 30 9 30 12 17 14 27

15
24 18
29 5
49 18
29 7
32 10
37 8
54 16
46

51 43 40 25 13 9

28
18 23
76 22
10 13
81 7
18 4
97

*Non responses are excluded from the computations of percentages.

Incident reporting and satisfaction The majority of participants (72
2%) did not file any report about the incident, with few reporting it either to the police (13%) or to their employer (5
6%). Reasons for not reporting the incident included the following: not considering it important (50%), not knowing how to report it (21
2%), being afraid of negative consequences (11
5%), feeling ashamed (4
5%) or incompetent (1
3%) and no one asked them to do so (0
6%). None of the participants said that guilt was a reason for not reporting the violent incident. Of those who said that WPV reporting procedures existed within the organisation (46
5%), the majority (62%) knew how to use them. Furthermore, only a minority of participants (35
2%) indicated the presence of encouragement to report WPV incidents, mainly from colleagues (70
3%) as well as the administration (29
7%), family (14
9%), union (6
8%) or friends (5
4%). Most of the participants (72
2%) said that no formal procedures were initiated by their employer to investigate the WPV incident. With regard to participants’ satisfaction of the way their employer handled the incident, 37
5% were ‘very dissatisfied’, 14
3% were ‘dissatisfied’, 20
8% were ‘neither satisfied nor dissatisfied’, 17
3% were ‘satisfied’ and 10
1% were ‘very satisfied’. © 2014 John Wiley & Sons Ltd Journal of Clinical Nursing

Table 4 Form of attack, victim’s reaction and result of the violent incident n

%*

174 17 11 9 6 5 4 3 0 0 1

88
8 8
7 5
6 4
6 3
1 2
6 2 1
5 0 0 0
5

115 30 23 3 24

58
7 15
3 11
7 1
5 12
2

117 68 54 30 27 17 4 2 2 16 7

59
7 34
7 27
6 15
3 13
8 8
7 2 1 1 8
2 3
6

†

Violent act Verbal abuse Push Spit Kick Slap Punch Use of object Bite Immobilisation Scratch Other Victim’s reaction† Handled it myself Called for help Someone else helped me Security alarm use No reaction Consequences for the victim† Anger Disappointment Stress Fear Humiliation Irritation Injury Incompetence Guilt No consequence Other

*Non responses are excluded from the computations of percentages. † Participants (196 respondents) could give multiple answers.

Logistic regression analysis Taking into consideration the various variables of the questionnaire that may have some association with WPV in EDs, two significant models are described in Tables 6 and 7. The reference category for the dependent variable for each model is the absence of violence in EDs, while the reference category for the predictors is indicated at its last row (odds ratio 1). Tables 6 and 7 provide information for the name of the variable, the estimation of parameter b’s of each category, Wald statistics, p-values, odds ratio and 95% CI for odds ratio. Values of odds ratio smaller than 1 indicate a drop in the incidence of violence in EDs by comparison with the reference category for each variable. Respectively, values of odds ratio >1 increase the incidence of violence in EDs in comparison with the reference category for each variable. Predictors in the first model ( 2 log

5

P Vezyridis et al. Table 5 Perpetrator’s characteristics

Relationship Patient Relative/friend Staff Other Gender Female Male Age (years) ≤18 19–30 31–50 51–65 ≥66 Impairment† Alcohol abuse Mental illness Narcotics Cognitive illness Medication None of the above Don’t know Don’t remember

n

%*

73 127 14 1

33
9 59
1 6
5 0
5

33 137

19
4 80
6

2 63 82 23 4

1
15 36
20 47
12 13
22 2
30

35 17 6 1 0 69 66 8

17
9 8
7 3
1 0
5 0 35
2 33
7 4
1

*Non responses are excluded from the computations of percentages. † Participants could give multiple answers.

likelihood = 56
274, p-value = 0
049) are nominal and ordinal variables: occupation, gender and years of work experience. Clearly, clinicians who are relatively inexperienced (five years or less) are more likely to experience WPV (p-value = 0
001). Specifically, if the ED clinician has work

experience of between one and five years, they face a WPV risk more than five times higher than that of an ED clinician with 20 years of experience (odds ratio 5
845). The second model is also significant ( 2 log likelihood = 45
344, p-value = 0
041). The predictors in the second model are waiting time (hours), the perpetrator’s gender and the incident location. It seems that WPV is more than five times more likely to happen within the first hour of the waiting time (p-value = 0
021; 5
184 odds ratio). Using the Pearson’s chi-square test of independence, no significant differences were detected between participant’s gender, occupation and perpetrator’s gender. Due to the small sample size (and small population), for some other characteristics, such as the participant’s age, years of work experience and the location of the incident, the test failed to give any significant results. What is very significant is the fact that the WPV was highly correlated (Table 8) with the consequences of anger and stress, participants’ feeling in advance that something was about to happen, their action in handling the incident themselves, their worry more about physical incidents (rather than verbal abuse or sexual harassment) and the absence of encouragement for reporting WPV.

Causal factors and prevention At the end of the survey, participants were also asked to indicate three factors that lead to verbal abuse and physical assaults in the ED as well as three measures that could be implemented so as to prevent such incidents from taking

Table 6 Wald statistics and odds ratios for exposure to workplace violence

B Occupation Doctor 0
193 Nurse Gender Male 0
224 Female Work experience (years) 20

SE

Wald

p-Value

Odds ratio Exp (B)

95% Confidence interval for Exp (B) Lower bound

Upper bound

0
487

0
157

0
692

0
824 1

0
318

2
140

0
363

0
383

0
536

1
252 1

0
615

2
548

1
209 0
555 0
460 0
573 0
671

0
254 10
136 1
255 0
440 1
499

0
614 0
001*** 0
263 0
507 0
221

1
839 5
845 1
674 1
462 2
273 1

0
172 1
971 0
680 0
476 0
611

19
668 17
333 4
123 4
490 8
460

***p-value ≤ 0
001.

6

© 2014 John Wiley & Sons Ltd Journal of Clinical Nursing

Original article

Workplace violence in Cypriot EDs

Table 7 Wald statistics and odds ratios for workplace violence to occur

B Waiting time (hours) 3 Perpetrator’s gender Male Female Incident location Triage Cubicle Emergency room Corridor Waiting area Other

SE

Wald

p-Value

1
646 0
951

0
714 0
778

5
310 1
497

0
021** 0
221

0
443

0
707

0
392

0
457 0
703 1
086 0
266 1
184

1
320 1
385 1
226 1
339 1
373

0
120 0
257 0
785 0
039 0
743

95% Confidence interval for Exp (B)

Odds ratio Exp (B)

Lower bound

Upper bound

5
184 2
589 1

1
279 0
564

21
016 11
891

0
531

0
642 1

0
161

2
569

0
729 0
612 0
376 0
843

1
579 2
019 0
338 0
767 0
306 1

0
119 0
134 0
031 0
056 0
021

20
987 30
496 3
729 10
575 4
516

**p-value ≤ 0
05.

place (Table 9). The most significant factors leading to both nonphysical and physical violence included patients’ attitudes (17
8, 23
8%, respectively), waiting time (17
5, 21
6%) and alcohol abuse (14
2, 9
6%). The three most significant measures to prevent WPV were better security (26
7%) through proper policing, Closed-circuit television (CCTV) and access control; education of the public in the proper use of the ED (15
2%); and positive attitude and behaviour from both patients and staff (10
9%).

Discussion This multisite study examined the perceived prevalence, precipitating factors, characteristics and consequences of workplace violence for ED clinicians. It also gathered clinician suggestions for addressing this phenomenon. The vast majority of clinicians (76
2%) who participated in the study reported exposure to WPV in the previous 12 months, although they (82
9%) did not take a sick leave as a result of the violent incident (Pinar & Ucmak 2011, Kitaneh & Hamdan 2012). They were also worried about physical assaults, although most of the violent incidents involved verbal abuse. Previous work has identified verbal abuse as the most frequent form of WPV in EDs (Jenkins et al. 1998, Crilly et al. 2004, Ferns 2005, Lin & Liu 2005, Farrell et al. 2006, James et al. 2006, Ryan & Maguire 2006, Kamchuchat et al. 2008, Gasc on et al. 2009, Zampieron et al. 2010, Esmaeilpour et al. 2011, Gilchrist et al. 2011, Lau et al. 2011, Hahn et al. 2013). © 2014 John Wiley & Sons Ltd Journal of Clinical Nursing

Previous international research indicates that lack of work experience is a major characteristic of the victims, with inexperienced young female nurses, rather than Table 8 Significant factors and consequences associated with workplace violence (WPV) in emergency departments No WPV

WPV

n

n

%*

%*

Worry about physical violence Never 13 38
2 21 61
8 Low 14 31
8 30 68
2 Moderate 10 20
8 38 79
2 Strong 4 14
3 24 85
7 Extreme 6 11
8 45 88
2 Feeling in advance about the incident No 19 20
4 74 79
6 Yes 7 7
7 84 92
3 Action: handled it myself No 19 23
5 62 76
5 Yes 12 10
6 101 89
4 Consequence: anger No 18 23
1 60 76
9 Yes 13 11
2 103 88
8 Consequence: stress No 27 19
3 113 80
7 Yes 4 7
4 50 92
6 Encouragement to report WPV No 26 19
3 109 80
7 Yes 23 31
5 50 68
5

p-Value

df

v2

0
023†

4

11
376

0
013†

1

6
150

0
016†

1

5
791

0
027†

1

4
895

0
043†

1

4
095

0
047†

1

3
94

*Non responses are excluded from the computations of percentages. † Significant variables associated with workplace violence prevalence, p-value < 0
05.

7

P Vezyridis et al. Table 9 Perceived factors leading to violence and preventive measures n

%*

64 63 51 33 26 23 23 21 5 51

17
8 17
5 14
2 9
2 7
2 6
4 6
4 5
8 1
4 14
2

77 70 31 24 23 17 16 7 59

23
8 21
6 9
6 7
4 7
1 5
2 4
9 2
2 18
2

88 50 36 24 22 17 17 10 5 2 59

26
7 15
2 10
9 7
3 6
7 5
2 5
2 3 1
5 0
6 17
9

†

Factors for verbal abuse Patients’ bad attitude Waiting time Alcohol abuse Substance abuse Patients with mental issues Lack of security Staff’s behaviour Improper emergency department (ED) use No fear of punishment Other Factors for physical assault† Patients’ bad attitude Waiting time Alcohol abuse Improper ED use Staff’s behaviour Substance abuse Patients with mental issues Lack of security Other Measures to prevent† More security Public education of proper ED use Positive attitude and behaviour More staff Punishment No relatives present Management’s support More space ED service fee More diagnostic and treatment equipment Other

*Non responses are excluded from the computations of percentages. † Participants could give multiple answers.

doctors, being more likely to report such incidents (Crilly et al. 2004, Kamchuchat et al. 2008, Gasc on et al. 2009, Esmaeilpour et al. 2011, Hahn et al. 2013). Their more experienced colleagues (with more than five years in the ED) seem to be at less risk (Hegney et al. 2003). In this study, after adjustment for gender, experience and occupation, only relatively inexperienced nurses and doctors were found to be at greater risk (Farrell et al. 2006, Gacki-Smith et al. 2009). Therefore, training in the management of these incidents should target inexperienced staff first. In the current study, violent incidents were more likely to take place during Friday or Saturday night shifts, in the assessment or treatment areas and within the first hour of waiting. Participants reported wait times as the most

8

significant organisational factor that led to WPV. These findings are in line with previous research which identified the common problem of ED wait times (Jenkins et al. 1998, Jones & Lyneham 2001, James et al. 2006, GackiSmith et al. 2009, Gasc on et al. 2009, Gilchrist et al. 2011, Lau et al. 2011) as a severe precipitating factor, with most violent incidents taking place around the first hour of presentation (Lavoie et al. 1988, Crilly et al. 2004), in the ED triage area (Pane et al. 1991, Crilly et al. 2004, Gates et al. 2006) and during the evening or night shifts (Dalphond et al. 2000, Crilly et al. 2004, Ferns 2005, Gates et al. 2006, Hilliar 2008, Zampieron et al. 2010). The typical perpetrator of a violent incident in the ED has been identified as a male patient around the age of 30 years (James et al. 2006, Zampieron et al. 2010, Lau et al. 2011, Magnavita & Heponiemi 2012) who develops either demanding behaviour or requests attention (Murray & Snyder 1991, Crilly et al. 2004, Lau et al. 2011). In contrast, our findings indicate that it is relatives or friends of the patient who are more likely to be involved in the incident, followed by the patient (Di Martino 2002, Gerberich et al. 2004, Ayranci et al. 2006, AbuAlRub et al. 2007, Gasc on et al. 2009, Esmaeilpour et al. 2011, Pinar & Ucmak 2011, Kitaneh & Hamdan 2012). Here, we should note that in Cypriot EDs, relatives are often (against regulations) present during patient’s treatment. For those perpetrators who initiated the violent incident, the study findings support other studies (Jenkins et al. 1998, Zernike & Sharpe 1998, Lyneham 2000, Catlette 2005, Gates et al. 2006, James et al. 2006, Kamchuchat et al. 2008, GackiSmith et al. 2009, Gasc on et al. 2009, Gilchrist et al. 2011) which highlighted alcohol intoxication, substance abuse and mental illnesses as primary diagnoses. Based on the review by Pich et al. (2010), a history of violent behaviour for repeated offenders or a history of having experienced violence has also been identified as predictive factors. In line with the findings of other studies (Jenkins et al. 1998, Adib et al. 2002, Farrell et al. 2006, Gates et al. 2006, AbuAlRub et al. 2007, Gacki-Smith et al. 2009, Gasc on et al. 2009, Esmaeilpour et al. 2011, Pinar & Ucmak 2011, Kitaneh & Hamdan 2012), severe underreporting of WPV occurred, with the vast majority of victims (72
2%) considering the incident as unimportant. Victims lacked knowledge on how to file a report or were afraid of negative consequences afterwards. As with other studies (Jenkins et al. 1998, Erickson & Williams-Evans 2000, Lyneham 2000, Gerberich et al. 2004, Ryan & Maguire 2006, Gacki-Smith et al. 2009, Pich et al. 2010, Pinar & Ucmak 2011, Kitaneh & Hamdan 2012), we found that the vast majority of our participants consider these © 2014 John Wiley & Sons Ltd Journal of Clinical Nursing

Original article

incidents as part of their ED work. This disposition may be strengthened by the lack of encouragement and support from the healthcare organisation to report the incident and initiate appropriate action. Similar to previous studies conducted in Asian countries (Kwok et al. 2006, Kamchuchat et al. 2008, Pai & Lee 2011), the majority of our participants reported that no administrative investigations had been carried out into the incidents. The main source of support and encouragement for reporting WPV had been their colleagues (Pinar & Ucmak 2011). Consequently, ED clinicians are largely left with the choice of having to resolve these incidents themselves. What is particularly worrying in this study (and in Cypriot EDs) is the fact that anger, which was strongly correlated with stress, was the predominant psychological consequence for the victim (Kitaneh & Hamdan 2012, Magnavita & Heponiemi 2012). Such conditions may create a stressful ED work environment ripe for violent responses by frustrated clinicians. In terms of addressing this phenomenon, ED clinicians in this study noted that better security measures (GackiSmith et al. 2009) and public education about the proper use of the ED could potentially reduce the prevalence of WPV. Previous work, which examined the effectiveness of various measures, concluded that lack of security or police presence (or their lack of response) seems to be a considerable organisational factor for precipitating such incidents (Gates et al. 2006). However, evidence of the effectiveness of other security measures, such as panic buttons, security cameras and controlled accesses, is still inconclusive or outdated (see May & Grubbs 2002, Phillips 2007, Anderson et al. 2010, Kowalenko et al. 2012). Metal detectors seem to have a positive effect on decreasing severity of physical assaults with the use of metal objects (Anderson et al. 2010). Several (mainly Anglophone) developed countries have adopted ‘zero tolerance’ policies for violent incidents (Jackson et al. 2002). Violence prevention and management training for staff (Ryan & Maguire 2006) has also been suggested as a practical and less confrontational strategy (Gates et al. 2006). It has good results in increasing staff confidence (Grenyer et al. 2004, Needham et al. 2005). However, there is only limited or weak evidence supporting the overall success of such approaches (Lin & Liu 2005, Kamchuchat et al. 2008, Kansagra et al. 2008, Gacki-Smith et al. 2009, Wassell 2009), reaffirming the need for better measurement of training effectiveness (Anderson et al. 2010, Gerdtz et al. 2013). While security staff, equipment and training seem to increase perceptions of safety among ED clinical staff, their limited effectiveness could increase their actual risk of WPV (Blando et al. 2013). © 2014 John Wiley & Sons Ltd Journal of Clinical Nursing

Workplace violence in Cypriot EDs

Lastly, we found ED attendees, especially male relatives or friends of the patient, were the majority of perpetrators, especially when compared with psychiatric patients or patients with alcohol or substance abuse issues. When our participants were asked, positive attitudes and behaviour for both the healthcare provider and the healthcare receiver were included in their list of possible preventive measures. Workplace violence is an unpleasant phenomenon that has been extensively studied in EDs. Various risk factors and consequences have been identified, and prevention programmes have been suggested at all levels of policy and practice. The direct and indirect financial implications of WPV in EDs have also been examined. For example, the English NHS has estimated the yearly cost of this phenomenon at £69 million or 4500 nursing salaries, excluding training costs for each nurse who leaves the service, the individual organisational cost of deploying security measures or the loss of productivity (Design Council 2011). We agree with Anderson et al. (2010) that it is time to move away from the differentiation of the magnitude of this phenomenon and to begin testing potentially effective interventions. At the same time, we are still bound to accept and discuss the considerable lack of reporting mechanisms or encouragement of reporting WPV, which has resulted in a substantial lack of official data. This situation obstructs acknowledgement of the magnitude and persistence of the phenomenon by managers and policymakers in some countries. Therefore, there is an evident need for studies that periodically survey front-line staff and assess levels of and risk factors for WPV to be able to develop culturally sensitive and context-specific interventions. The ICN (ILO 2002) and the Emergency Nurses Association (2011) have acknowledged this need and have developed appropriate guidelines and tools. The next step forward requires health officials and clinical leaders to move beyond organisationcentred interventions targeting clinicians to the development of wider initiatives and educational programmes that gives citizens a better understanding of the complex and dynamic nature of ED work before they become service users.

Limitations of the study The study used self-reported data to determine the frequency and characteristics of violent incidents. Therefore, memory biases might have affected the accuracy of reporting. Also, the overall response rate to our questionnaire was 60
27%, and while we adjusted for nonresponse, the results might have been biased, particularly for doctors

9

P Vezyridis et al.

(response rate, 36
93%). However, our sample is representative of the nation as all (rural and urban) EDs in Cyprus participated in this study.

also like to thank Associate Professor Judith E. Arnetz for the permission to translate the VIF into the Greek language and Associate Professor Stephen Timmons for proofreading our manuscript.

Conclusion and relevance for clinical practice The findings of this study, the first in Cyprus, corroborate previous international research on the mounting issue of workplace violence in EDs. Verbal abuse is common in Cypriot EDs, but clinicians are more worried about physical assaults. Clearly, there is more to be done on prevention and management of WPV. The encouragement of reporting and support after the violent incident would be the first steps to increase employees’ confidence that effective action will follow. Violent incident training appropriate to this workplace and new security policies could also be introduced. At the same time, more research is needed to examine the antecedents and consequences of WPV from the perpetrator’s viewpoint.

Disclosure The authors have confirmed that all authors meet the ICMJE criteria for authorship credit (www.icmje.org/ethical_ 1author.html), as follows: (1) substantial contributions to conception and design of, or acquisition of data or analysis and interpretation of data, (2) drafting the article or revising it critically for important intellectual content, and (3) final approval of the version to be published.

Funding No funding was received by the authors for the study or preparation of the manuscript.

Acknowledgements

Conflict of interest

The authors would like to thank all the emergency department clinicians who participated in this study. We would

The authors declare that they have no conflict of interests.

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Workplace violence in Cypriot EDs

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