Transcript Violence in Emergency Departments in Palestine: Prevalence

Violence in Emergency
Departments Against
Nurses in Palestine
Prevalence and Prevention
Naji Abu Ali
2004
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.
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.
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.
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.
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.
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
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.
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.
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
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).
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, wellbeing or health (ICN, 2003. page 2)’.
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 ED’s .
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.
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.
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.
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.
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).
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.
Sample

The sample included all nurses
working in EDs in 9 hospitals in the
West Bank and Jerusalem which
represent 3 major geographical areas
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
Socio-demographic characteristics
of respondents, Palestine
Frequency (N)
Percent (%)
- 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
Age Distribution
Physical and Verbal violence
distribution
60
40
20
0
Series1
physical
verbal
31
60
Time of physical attack
18
16
14
12
10
8
6
4
2
0
Series1
Don't
0700 - before 1300 - before 1800 - before 2400 - before
Remember
0700
2400
1800
1300
17
4
2
3
7
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
Don’t know
8.0
10.8
Other
1.0
1.4
Total:
74
100.0
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
Don’t know
6.0
8.5
Total:
71
100.0
Formal education in relation to violence
120.00%
100.00%
80.00%
60.00%
40.00%
20.00%
0.00%
No
Communication
Safety
measures
Stress
management
Causes &
prevention of
viol
Yes
Conclusion


The prevalence of verbal abuse was reported
by the majority of the respondents and onethird 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.
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.
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.
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.
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.
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.
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.
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.
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.
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.