Violence in Emergency Departments Against Nurses in Palestine Prevalence and Prevention

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Violence in Emergency Departments Against Nurses
in Palestine Prevalence and Prevention

• Naji Abu Ali
• 2004

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Acknowledgments

• Sincere appreciation is extended to my Direct
  Supervisor Jonathon Drennan for all his help,
  support, and encouragement and who made this
  research such an enjoyable experience.
• Much appreciation also to Professor Pearl Treacy
  for her kind direction, support and
  encouragement, which I will never forget.
• Sincere thank to Itaf Maqbul, my local supervisor
  in Palestine, for her support, encouragement,
  help and for her generous time.

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Introduction

• Many research studies show that violence and
  aggression in the workplace have increased in
  recent years.
• Moreover, they show that the prevalence of
  violence is six times higher in health sectors.
  Personnel in the front line as in the emergency
  department (ED) are more susceptible to violence
  and assault.

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Introduction

• The true incidence of violence is difficult to
  determine, due to different definitions of
  violence.
• There is evidence of under-reporting of violent
  behaviours and lack of formal education and
  training in relation to dealing with violent
  patients.
• There is also lack of support for victims in the
  health care sectors.

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Problem Statement

• Violence and physical assault in emergency
  departments (EDs) are recognized as significant
  occupational hazards for nursing professionals.
  Violence in societies increases and become a
  second leading cause of death in some societies
  (Mayer et al 1999). To detect the prevalence of
  violence in the ED, and to increase staff
  awareness of violence this study was conducted.

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Problem Statement

• To ensure safe working environment in EDs, nurse
  managers must provide training for nursing staff
  in relation to prevention and responding to
  violence and aggression. Nurses should understand
  that violence result from a number of variables,
  like stress, pain, fear of unknown, extended
  waiting time to be seen and treated and
  unpleasant environment.

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Purpose of the study

• The main purpose of the study is
• to investigate the prevalence of violence in
  emergency departments and factors used by ED
  staff to prevent such violence

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Research site

• The study was conducted in 9 hospitals within an
  area of 80-square kms in Palestine. The hospitals
  were located in three different geographical
  areas.

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Significance of study

• Violence increases in society
• There is a lack of data in relation to the
  prevalence of violence in EDs in Palestinian
  hospitals, so staff and community awareness will
  be increased through this research,
• The development of explicit policies in relation
  to violence and how to respond to it.

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Significance of study

• The study will also increase the awareness of
  health management in health care settings of the
  importance of selection criteria as to the
  characteristics of nurses and their
  qualifications when being assigned to EDs

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Definition of Violence

• Violence is a difficult term to define (Brennan,
  2000). Dennen (1980) discovered 106 definitions
  of the term.
• Violence is defined as any incident in which a
  person is verbally abused, threatened or
  assaulted, psychologically or physically by a
  patient or member of the public, fear or the
  application of force arising out of the course of
  their work whether or not they are on duty
  (Health and Safety Commission, 1997, Rippon 2000,
  Beale et al 1999, RCN, 1998).

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Definition of Violence

• In this study violence defined as Incidents
  where staff are abused, threatened or assaulted
  in circumstances related to their work, involving
  an explicit or implicit challenge to their
  safety, well-being or health (ICN, 2003. page
  2).

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Causes of violence

• Individual factors For example, mental
  illness, alcohol or drug usage.
• Organisational factors as well as Environmental
  factors, such as poor lighting, poor security,
  unpleasant waiting areas and the layout of EDs .

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Causes of violence

• Understaffing may increase the risk of violence
  due to longer patient waiting times and workers
  being alone with patients.
• Workplace stressors, such as low supervisor
  support, work overload and poor professional
  relationships.

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Theoretical framework

• Psychoanalytical and Behavioural approaches are
  an appropriate theoretical framework for this
  study. Freud (1920) saw aggression as a response
  to pain and frustration.

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Theoretical framework

• Behavioural perspective suggests that human
  aggression is acquired and maintained through
  reinforcements and punishment.
• Through the daily humiliation and punishment to
  most Palestinian peoples, mainly the adults.
  Their aggression is then turned against their
  family members.
• The children in such society acquire this
  aggressive behaviour and it is reinforced through
  play, imitating what they see in the TV, street,
  school and home.

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Prevention of workplace violence

• Any prevention program requires strong commitment
  from health-care administration, and a clear
  written policy for job safety and security,
• Clear information provided to the patients and
  relatives about waiting time, with comfortable
  surroundings in which to wait, can relieve the
  stress and anxiety that may result in violence.

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Prevention of workplace violence

• Ensuring adequate members of trained and
  experienced staff
• A triage system is valuable in the improvement of
  communication between staff and patients. During
  triage, the patient can be assessed and gain
  information related to illness and injury and
  waiting time (Williams, 1992).

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Prevention of workplace violence

• The security system in the emergency departments
  is important to limit the risk of aggression to
  staff and patients.
• Measures such as
• security screens
• closed circuit TV cameras
• security guards
• direct links to police station
• Nursing involvement in policy development of
  security measures within the ED, and
  participation on safety committees.

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Sample

• The sample included all nurses working in EDs in
  9 hospitals in the West Bank and Jerusalem which
  represent 3 major geographical areas

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Sample

• The sample size was 99 nurses who met the
  eligibility criteria of
• Nurses who work in EDs in Palestine
• Nurses including LPN and RN
• Nurses who work at least 21 hours per week
• Nurses who have experienced more than 3 months in
  EDs
• Nurses who work in one of the 9 hospitals

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FINDINGS
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Socio-demographic characteristics of respondents,
Palestine
Frequency (N) Percent ()
Age Distribution
- 25 17 19.1
26-44 59 66.3
45 13 14.6
Total 89 100.0
Gender of Respondent Male 64 69.6
Female 28 30.4
Total 92 100.0
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Which changes have occurred in the workplace in
the last 2 years?
N
None 21 28.4
Restructuring/reorganization 12 16.2
Staff cuts 22 29.7
Increased staff numbers 6.0 8.1
Restriction of resources 3.0 4.1
Additional resources 1.0 1.4
Dont know 8.0 10.8
Other 1.0 1.4
Total 74 100.0

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Impacts of changes on daily work
Item N
None 15 21.1
Work situation for staff worsened 35 49.3
Work situation for staff improved 7.0 9.9
Situation for patients/clients worsened 4.0 5.6
Situation for patients/clients improved 4.0 5.6
Dont know 6.0 8.5
Total 71 100.0

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Conclusion

• The prevalence of verbal abuse was reported by
  the majority of the respondents and one-third had
  experienced physical attack in the last 12
  months.
• The main perpetrators of violence were
  relatives, followed by patients. The most
  frequent time of physical attack happened between
  7.00 am and 1.00 pm.

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Conclusion

• The most common type of support given by the
  employer was the opportunity to speak about and
  report the incident in cases of both physical and
  verbal violence.
• In general, the victims were dissatisfied with
  the way the incident was handled in the
  workplace.
• Reporting of violent incidents by victims was
  low, as they think it is useless and not
  important.

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Conclusion

• Respondents think that restricted public access,
  improved surroundings, restricted exchange of
  money at the workplace, patient screening,
  training, investment in human resource
  development and reduced periods of working alone
  could be helpful in minimizing workplace violence.

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Recommendations for management

• It is recommended that
• All employers should provide a formalized
  structure of support for all staff who have been
  assaulted while at work.
• Referral to professional counselling to be
  available to victims when needed.
• Nurse Managers should be supportive to nurses who
  have been assaulted in the context of blame
  culture.
• Nurse Managers should encourage the reporting of
  assault.

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Recommendation for training

• It is recommended that
• All staff who have direct contact with patients
  should have basic training related to
• Communication
• How to deal with violent behaviour.
• Stress management.
• Safety measure in EDs.
• All staff in EDs should be qualified to work in
  the ED by having specialized courses in
  emergency.

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Recommendations for policy development

• It is recommended that
• There must be a policy which is comprehensive and
  consistent in relation to reporting aggression
  and situations of assault
• Develop a comprehensive official form for the
  reporting of violent incidents
• Develop a policy on how to deal with violent
  behaviour
• Ensure that all staff is familiar with this form
  and how to fill it in appropriately.

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Recommendations for policy development

• Ensure that management encourage reporting of
  such incidents
• Develop a policy about the antecedent and
  consequences of assault.
• Develop a policy that supports the victims
  physically and emotionally in the event of an
  incident of assault.
• Develop a policy to recruit staff in the EDs
  where the levels of abuse is excessive.

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Recommendations for policy development

• It is the responsibility of the manager to study
  all violent incident and create a policy in how
  to deal with violent behaviour.
• Recruitment of staff in EDs.
• In service education related to communication and
  stress management.
• Existence of efficient preventative measures that
  help to prevent or decrease violent behaviours
  like security measures, comfortable environment,
  decrease waiting time, availability of resources.

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Staffing

• Availability of sufficient staff members on all
  shifts to decrease waiting time.
• Orientation programme for new staff.
• Staff should be qualified and have good
  communication skills.

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Recommendations for further research

• It is recommended that
• A wider study to include all clinical
  specialities to investigate the prevalence of
  violence incidents and prevention measures..
• Further research to investigate the causes of
  violent behaviour in health settings.
• Further research to identify components of an
  effective training programme to assist in the
  prevention and management of violent behaviour.
• Further study to improve reporting systems in
  relation to aggression and violence in the health
  workplace.

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Naji Abu Ali
Thank You