Violence in Emergency Department - Literature review Example

Violence in Emergency Department Name: Unit: Course: Supervisor: Date of submission: Background Violence in the work place has been a growing concern among workers in various disciplines. For a long time, there has been little attention on the violence workers experience in the cause of their duties. School and workplace shooting experienced in United States of America drew a lot of attention and raised the public consciousness on violence in places of work. In America, the Bureau of Statistics (2010, p.2) estimated that 1.7 million workers receive work related injuries. Studies conducted in the healthcare setting; show that nurses and patient care assistants are prone to violence from patients and the caretakers of patients. This violence includes both physical and verbal assault. In healthcare setting the Emergency Department (ED) nurses and physicians, experience the highest rate of assault (Gates, Gillespie & Succop 2011, p. 62). According to Gacki-Smith et al (2009, p. 342) emergency department remains to be a vulnerable setting for violence in health care centres because there is no standardized mechanisms for reporting violence in the setting and the assumption that violence cannot happen in such a place. Violence that occurs in ED department affects negatively on the healthcare givers and the patients. It reduces productivity, causes physical injury and psychological issues to the health caregivers. Literature review Violence against workers in the emergency departments is prevalent across the globe. Kitaneh and Hamdan (2012, p. 1) carried out a study to assess the magnitude, incidence and consequences of violence against physicians and nurses in emergency departments in public hospitals in Palestine. The study employed a cross-sectional study design in which a self-administered questionnaire was used to collect data on the different aspects relating to workplace violence in five hospitals. Through a stratified sampling, 271 physicians and nurses were incorporated in the study and given the self-administered questionnaires. Of the 271 questionnaires, administered 88.7% (240) questionnaires were satisfactorily completed. The analysis of the data was done in which Pearson’s chi-square was used in testing of the differences in non-physical and physical exposure to violence based on the responses given by the participants. Logistics regression model was used to assess the confidence intervals (Kitaneh & Hamdan 2012, p.3). Of the 240 nurses and physicians that participated in the study, 80.4% reported having experienced violence in the past 12 months. Non-physical violence was 59.6% while the physical violence accounted for 20.8%. This study did not find significance differences between exposure to violence between nurses and physicians. The perpetrators of violence were mainly the visitors and patients relatives. Patients and co-workers were also found to be cause of the violence (Kitaneh & Hamdan 2012, p.6). This findings support Parish (2013, p 241) who pointed that violence against healthcare givers in ED is widespread and goes unreported in most health facilities. The use of the chi square to carry out the analysis ensured that there was no bias in the analysis. The sampling method also ensured equal representation in the hospitals selected. However, the use of the self-administered questionnaire could have resulted to response bias as the participants were not guided on the process. These findings poses a question on what measures should administrators of hospitals and ED departments take to reduce the problem. Wolf and Parhats (2013, p. 2) carried a study to explore the experiences of the nurse working in ED in various hospitals in US. The study design employed was a qualitative descriptive exploratory design. Forty six (46) nurses were sampled, through an e-email, the nurse were to write narrative to describe their experience in the emergency departments in the process of care giving. The analysis of the narratives form the nurses were by a narrative analysis and constant comparison that were used to point to the emerging themes in the narratives. Key themes identified in the narratives pointed to violence as becoming endemic in the workplace. The narratives also identified that there was a culture of acceptance of violence that resulted in many cases not being reported (Wolf and Parhats 2013, p. 4). Findings of this study are in line with earlier studies conducted by Chapman et al (2010 p.187) that found that despite of the high cases of violence, there is a culture of acceptance and lack of cue recognition that harbours the reporting of the ED violence. Chapman et al (2010, p.191) pointed that the in ED the violence is common; however, the healthcare givers have developed a normalization of the issue that has been the main cause of lack of intervention. Main strength of the study is use of descriptive process that ensured that nurses narrated the episodes in detail. However, sample size of 46 participants is relatively small for the generalization of the results (Wolf and Parhats 2013, p. 5). A research conducted by Gilany, Wehady and Amr 2010, p. in Turkey established that work place violence was a great issue that was on increase. Rueanyod (2014, p. 1) carried a study to determine the frequency and factors that caused violence against nurses in ED. The study was conducted in Thailand’s capital of Bangkok. Seven hospitals ED were included in the study in which 237 participants were included in the study. The study data was collected by use of questionnaire. The analysis of the data was through descriptive statistics, odd ratio and chi square tests (Rueanyod 2014, p. 3). The results pointed that, in a period of over a year participants had experienced abuse. Seventy percent (70%) had experienced verbal abuse while 10.1% were subjected to physical abuse. The cause of the abuse was mainly from the relatives of the patients that accounted for 83.3%. Patients accounted for 44.6%. Nurses aged below 30 years experienced more cases of abuse. The implication of the abuse was stress and anxiety (Rueanyod 2014, p. 3). A similar study conducted by Gillespie et al (2010 p. 72) supports the findings that the main consequence of the ED violence is psychological disorders. The data collection was through a self-reported retrospective method (Rueanyod 2014, p. 4). This meant that the study relied on memory of participants that could have caused a recall bias. In addition, the seven hospitals were limited to Bangkok. However, the study design and sampling ensured true representation of the nurses in the identified hospitals and within Bangkok. Gacki-Smith et al (2009, p. 340) conducted a cross-sectional study with the aim of investigating experiences and perception of nurses in course of work at ED. A cross sectional study was used in which registered nurse members in US were eligible for the study. 3465 nurses were included in the study and they completed a study questionnaire that had 69 items. Various statistical tools for data analysis were used. They included the use of SPSS and chi square tools. Out of the nurses included in the study, 25% reported to have been subjected to violence for over 20 times in the past three years while 20% reported having experience verbal abuse for over 200 times in the past 3 years. The nurses who experienced violence either verbal or physical reported that they feared retaliation and that they felt there was no enough support from hospital administration (Gacki-Smith et al 2009, p. 344). The findings of this study are consistent with a study carried in Canada by Miedema et al (2011, p. 1429) in which incidents of violence against caregivers were found to be high and went unreported. The use of large study sample served as the main strength of the study as generalization could be made. The study was extensive and covered many hospitals in US. However, there is likelihood of respondent bias as the study relied on memory of respondents over three years period. Shahzad and Malik (2014, p, 241) carried a research that examined violence incidence in the work of nurses and how the violence affected their work. A qualitative approach was adopted. The analysis of the results was through NVIVO-10 and Grounded Theory method (Shahzad & Malik, 2014, p, 243). The results found that majority of the nurses had experienced violence in ED in the previous six months. The study established that the common type of violence was verbal, which nurses did not bother to report. Nurse affirmed that the violence demoralized them, resulted to stress and generally affected their quality of work in ED (Shahzad and Malik (2014, p, 244). The study findings support the literature that many cases of violence go unreported despite of the grave consequences on the nurses and the patients. The use of the qualitative data ensured that in-depth perceptions of the nurses were captured. In another study, Taylor and Rew (2011, p. 1072) conducted a research that was aimed at synthesizing the literature on work place violence in ED and establish interventions that were put in place. This was a systematic literature review. The searches for the related literature were done using online databases that included CINAHL, PsycInfo and Medline. The systematic review of the databases found that most of the studies focused on the incidence rates of the violence in ED and seldomly on its effects on nurses (Taylor & Rew, 2011, p. 1073). The study established that there was prove of widespread incidences of violence. The common themes reviewed were lack of reporting, attitudes and administration barriers that prevented means to reporting and intervention. Underreporting of violence in ED is common across different hospitals and countries and it is the main cause of the difficulties in tracking the violence and hence scarce information on the effects to the nurses and physicians (Malek, Sera & Selma 2011, p. 719). According to Saimai and Tanjra (2010, p.122) violence in nursing is an old phenomenon which for many years little attention has been paid. Rodwel and Demir (2012, p. 6) noted that this is due to lack of system for reporting such incidents especially in ED. Chen, Ku and Yang (2013, p. 798) carried a study that was aimed at exploring the rate of occurrence and types in Taiwan public hospitals. The study design used in this research was a descriptive correlation study. The collection of information was through structured questionnaires. Through random sampling, 880 nurses working in public hospitals in southern Taiwan were included and given invitations to complete the structured questionnaires. The response rate of the nurses was 89.9%. Data obtained was analysed using qualitative analytic methods. The results were analysed on basis of nurses working in ED, those in surgical departments and in intensive care units (Chen, Ku and Yang, 2013, p. 801). Nurses working in outpatient and emergency units were found to experience more violence in terms of verbal and physical assault compared to those in other departments. The use of comparative design ensured that there was a strong basis for drawing conclusion based on happenings in other departments. Even though the study was comprehensive and covering the different hospital departments, it did not include the primary causes of the violence. Verbal and physical assaults have been reported as the main type of violence that is subjected to healthcare givers in hospitals. In the healthcare sector, nurses have been found as being prone to the violence than the other caregivers. Rafati, Zabihi and Hosseini (2011, p. 5) endeavored to carry a study that assessed the extent of verbal and physical violence on nurses in the Babol University of Medical Sciences Hospital using a descriptive study. This was a descriptive study. All the nurses employed in the hospital were included in the study (n=302). A standardized questionnaire was used. The data collected using the questionnaire was analysed using analytic and descriptive processes in which Chi square and Fisher tests were used. The results showed that over 70% of nurses experienced violence in the course of their work in the hospital. The violence varied depending on gender with male nurses experiencing more violence than female nurses do. Most of the violence was from relatives of the patients and the patients themselves. Relatives accounted for 40.4% of the cases of violence (Rafat, Zabihi & Hosseini, 2011 p, 9). Raeda and Ali (2013, p. 4) carried a study that was aimed at assessing the incidence and frequency of psychological violence, exploring the complaints and the reaction of the nurses after the violence and identifying the contributing factors to the ED violence. A descriptive study design was used and a sample of 442 nurses from Jordan was used in the study. Collection of information was through a questionnaire. The questionnaire used was the workplace questionnaire developed by International Labor Office and International Council of Nurses in 2003. Results showed that 69% of nurses had been exposed to verbal abuse in workplace. Nurses attached to the ED reported more cases of abuse compared to nurses in other departments. The families of the patients were the main perpetrators of verbal abuse. The study also found that administration of the hospitals had no policies that protected the nurses and other workers from the psychological abuse workplace violence. As a result, nurses did not report the cases (Raeda & Ali 2013, p.10). Gates, Gillespie and Succop (2011, p. 59) carried a study that examined how violence from patients and patient relatives affects the work productivity in emergency departments. A cross sectional study design was applied. The nurses included in the study were members of Emergency Nurses Association in United States. By randomization, survey questionnaire were sent to 3000 nurses. Only 264 were returned which represented 8.8%. The survey questionnaire was divided into four sections, in which the first section was for the nurses to provide a narrative of a violent event that caused them stress. The second part consisted of the impacts of the events; the third part was about the productivity of the nurses after the incidence while the fourth part was the demographics of the participants (Gates, Gillespie &Succop 2011, p. 62). Ninety-Four (94) percent of nurses reported to having experienced at least a posttraumatic stress after a violent incident. The cases of violence in ED had significant relationship with stress symptoms and reduced work productivity (Gates, Gillespie &Succop (2011, p. 62). These findings confirm that the violence in workplace is one of the significant stressors for the nurses working in the ED as was established by Abbas et al (2010 p. 29-43) in a epidemiology of workplace in Egypt. The findings also support literature that violence has a negative impact on the care ED nurses give. Recommendations These studies affirm that workplace violence is a big issue in many hospitals around the globe and it is a major concern for nurses working in ED. A key theme in the studies is that many incidents of violence either physical or verbal go unreported. In assessing the effect of the violence on productivity, Gates, Gillespie and Succop (2011, p. 65) found that there was significant correlation between low productivity after a violence incident. The hospital managements should make a priority to device a reporting system for the different types of violence that take place in ED. Violence in ED should not be normalized; there is need for policies to be enacted to regulate issues that relate to ED violence. The policies should include mechanisms for debriefing the affected nurses. This should be coupled with education to all healthcare givers on how to handle, prevent and reporting violent incidents. Summary LITERATURE REVIEW SUMMARY TABLE Author/s (Year) Country Aims Sample/ setting Design/ methods Main findings Strengths and limitations of the study Chen, K., Ku, Y. and Yang, H. 2013 Taiwan To explore the rate of occurrence and types of ED violence N=880 nurses Setting: Public hospitals in southern Taiwan Descriptive correlation study -ED were found to experience more violence -Verbal and physical violence Patients relatives main perpetrators of violence Strengths: comparative design ensured that there was a strong basis for drawing conclusion Weaknesses: use of structured questionnaire could have limited the data collected. Gacki-Smith, J., Juarez, A., Boyett, L. Homeyer, C., Robinson, L. and Maclean, S. 2009 United States of America To investigate experiences and perception of nurses in course of work at ED. N=3465 Setting: ED in US Cross-sectional A study questionnaire used to collect data -25% reported to have been subjected to violence for over 20 times in the past three years -20% reported having experience verbal abuse for over 200 times in the past 3 years Strengths: generalisations could be made due to large study sample representing different ED in US. Weaknesses: Possibility of respondent bias due Gates, D. Gillespie, G. and Succop, P. 2011 US To investigate how violence from patients and patient relatives affects the work productivity in ED N=264 Setting: US Cross-sectional Survey questionnaire -94% reported having experienced traumatic experience Weaknesses: possibility of respondent bias Strengths: random sampling ensured ta true representation of the population Kitaneh, M. and Hamdan, M. 2012 Palestine Assess the magnitude, incidence and consequences of violence against physicians and nurses N=240 Setting Public hospitals in Palestine Cross-sectional Questionnaires used to collect data -80.4% experienced violence -Non physical violence was 59.6% -Physical violence was 20.8% Weakness: response bias due to self administered questionnaire Strengths: sampling procedure which gave representative sample Rafati, R. Zabihi, A and Hosseini, S. 2011 To assess the extent of verbal and physical violence on nurses N=302 Setting: Babol University of Medical Sciences Hospital Descriptive study Data collection: questionnaires -70% of nurses experienced violence -Relatives accounted for 40.4% of the cases of violence Weakness: it was based on one hospital thus difficult to draw generalisations. Strengths: Descriptive process captured the perceptions . Raeda, F. and Ali, H. 2013 Jordan To assess the incidence and frequency of psychological violence N=442 Setting: Jordan Public hospitals Descriptive study -2003 International Labor Office and International Council of Nurses questionnaire -69% exposed to verbal abuse in workplace -ED nurses reported more cases Strengths: extensive questionnaire that captured various issues relating to work violence. Shahzad, A. and Malik, R. 2014. Pakistan To examine violence incidence in the work of nurses and how the violence affected their work Setting: Pakistan ED A qualitative approach -Majority of nurses reported being stressed -productivity decreased Strengths: the qualitative approach captured the different perceptions of the nurses. Weakness: the study sampling mechanisms were not provided. Rueanyod, W 2014 Thailand To determine the frequency and factors that caused N=237 Setting: Bangkok public hospitals Descriptive study self-reported retrospective Questionnaires used -70% of nurses experienced verbal abuse -10.1% physical abuse. -83.3%. caused by patients family -44.6% caused by patients Weakness: respondent bias due to forgetfulness, concentrated on Bangkok only. Strengths: comprehensive coverage of past events Taylor, J. and Rew, L 2011 To synthesize the literature on work place violence in ED Databases: CINAHL, PsycInfo and Medline Systematic review - widespread incidences of violence (lack or reporting, attitudes) Weakness: the study covered only three online databases. Strengths: systematic review pointed to major themes and covered different studies in different times. Wolf, A. and Perhats, C. 2013 US To explore the experiences of the nurse working the ED N=46 US ED Qualitative descriptive exploratory design - violence in ED becoming endemic Strengths: Descriptive process ensured that the nurses narrated incidents in detail Weaknesses: Small sample size used. References Abbas, M. Fiala, L. Abdel, R, and Fahim, A. 2010. Epidemiology of workplace violence against nursing staff in Ismailia Governorate. Journal of Egypt Public Health Association, 85 (1), pp. 29–43. Chapman, R., Styles, I., Perry, L., Combs, S. 2010. 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Verbal and physical violence on nurses in hospital of Babol University of Medical Sciences. Journal of Hayat 17 (2), pp. 5-11. Raeda, F. and Ali, H. 2013. Psychological violence among Jordanian Hospital nurses. Journal of Trans-cultural Nursing, 25 (4), pp. 3-9. Rueanyod, W 2014.Workplace Violence among Nursing Personnel in Emergency Department in Bangkok Thailand. Royal Thai Air Force Medical Gazette, 60 (1), pp. 1-9. Saimai, W. and Thanjira S. 2010. Workplace violence and its management by nursing personnel in emergency department. Ramathibodi Nursing Journal, 16 (1), pp. 121-135. Shahzad, A. and Malik, R. 2014. Workplace violence: An extensive issue for nurses in Pakistan - A qualitative investigation. Journal of Interpersonal Violence, 29 (18), p. 241-246. Taylor, J. and Rew, L. 2011. A systematic review of the literature: Workplace violence in emergency department. Journal of Clinical Nursing, 20 (7), pp. 1072-1085. US Department of Labor, Bureau of Labor Statistics. (2010). Nonfatal occupational injuries and illnesses requiring days away from work, 2010. Available at: http://www.bls.gov/news.release/archives/osh2_11092011.pdf. [Accessed October 25, 2014]. Wolf, A. and Perhats, C. 2013. Nothing changes, nobody cares: Understanding the experience of emergency nurses physically or verbally assaulted while providing care. Journal of Emergency Nursing, 1 (1), pp, 1-6. Read More