Violence in Emergency Nursing & Triage. Dr Jacqueline Pich School of Nursing & Midwifery, University of Newcastle, NSW.

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Beatrix Hodges
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Midwifery, University of Newcastle, NSW.

1 The VENT Study: Violence in Emergency Nursing & Triage Results from a national Australian study Dr Jacqueline Pich School of Nursing & Midwifery, University of Newcastle, NSW.. Presentation at 2015 ANMF (Vic Branch) Australian Nurses and Midwives Conference Melbourne, September 10-11, 2015

2 Background Violence in health sector increasing in severity & prevalence ED one of highest risk settings Nurses especially vulnerable Patients most common perpetrators

3 Aim Summary of the results from The VENT Study: a national study of Australian ED nurses experiences with patientrelated violence (quantitative data).

4 Definition of patient-related violence To ensure consistency of understanding amongst respondents Violence: refers to verbal abuse & threats, sexual harassment as well as physical assaults Explicit or implicit challenge to nurses well-being, safety or health at work

5 Study Design National cross-sectional survey distributed to 1150 members of the College of Emergency Nursing Australasia (CENA) Response rate = 51% (n = 537) 75 item survey developed using current literature on topic and tested with expert panel Option of paper or online survey Quantitative data analysed using Stata software package & descriptive statistics where applicable Free-text answers analysed using content analysis to create categories Coding checked by 3 reviewers

$Demographic profile of sample Employment fraction: Full-time (51%) & Part-time & casual (49%) Average hours per week in patient care: 32 hours Years of nursing experience: mean = 19 years Years of ED$

6 Demographic profile of sample Employment fraction: Full-time (51%) & Part-time & casual (49%) Average hours per week in patient care: 32 hours Years of nursing experience: mean = 19 years Years of ED experience: mean = 13 years Age: mean: 42 years (60% aged over 40) Classification: majority RNs (99%) Regional analysis: Metropolitan (n = 233) Regional (n = 218) Remote/other (n = 21) Geographical Location: All states & territories in Australia were represented

7 Results

8 Point prevalence of episodes of violence 87% (n = 455) reported experiencing an episode of patientrelated violence in the previous 6 months 40% (n = 211) reported that they had been involved in an episode in the previous week Number of reported episodes ranged from 1 to 100 with an average of 15 per nurse No statistical difference between metropolitan & regional/remote areas 79% (n = 403) perceived that the frequency of violent episodes was increasing & 93% (n = 473) that it was inevitable

9 Age & experience of nurses Logistic regression conducted on episodes of violence experienced in last 6 months Age Younger nurses more likely to experience an episode of violence As age increased the likelihood decreased Years of Experience Relationship between years of nursing/ed nursing experience and experiencing an episode of violence numbers reporting violence decreased as years of experience increased Age & years of experience Years of experience more significant than age

10 Odds ratios: 3.63 p<0.001 for Triage 3.13 p<0.001 for Patient cubicles 1.85 p = for Waiting room High risk areas of the ED Area of the department n = 499 % response Triage Patient cubicles Waiting room

11 High risk nursing activities Nursing activity n = 496 % response Triaging Communicating with patients Managing patient reactions to delays Odds ratio of 2.91 p<0.001 for Triaging

12 Odds ratio of 3.38 p<0.001 for Alcohol intoxication 3.30 p<0.001 for Mental health diagnoses 2.54 p<0.001 for Substance abuse Antecedents & Precipitants: Clinical Presentation Diagnoses n = 491 % response Alcohol intoxication Mental health diagnosis Substance abuse

13 Odds ratio of 6.05 p<0.001 for Alcohol intoxication 4.82 p<0.001 for Substance abuse 2.85 p<0.001 for Mental health diagnoses Patient specific factors Factor n = 512 % response Alcohol intoxication Substance abuse Mental health diagnosis Cognitive dysfunction also significant

14 ED specific factors Factor n = 508 % response Delays/waiting times Over-crowding Lack of privacy Cognitive dysfunction also significant Odds ratio of 5.11 p<0.001 for Delays

15 Highest risk factors Logistic regression modelling top 3 risk factors to emerge 1. Triage (OR = 2.72; p<0.001) 2. Alcohol intoxication 3. Substance abuse

age & innuendo e.g. re appearance & competence Repetition over hours/days

16 Verbal abuse Experienced by 95% (n = 511) Swearing (n = 504, 99%) Gender based : sexual language & innuendo e.g. re appearance & competence Repetition over hours/days due to waiting times & bed block Attempt to assert dominance or control over a situation and erode the self-worth and self-confidence

Physical abuse Most frequent types of physical abuse n = 468 % response Destructive behaviour 376 80 Spitting 335 72 Kicking 321 69 Punching 286 61 Pushing 285 61 *multiple responses were allowed

17 Physical abuse Most frequent types of physical abuse n = 468 % response Destructive behaviour Spitting Kicking Punching Pushing *multiple responses were allowed for these items 87% of nurses (n = 468) had experienced physical abuse in the study period The use of weapons was reported by 65% (n = 303) of these nurses 13 nurses (3%) had been sexually assaulted

Impact on nurses Injuries 95 (18%) nurses reported that they had suffered a physical or psychological injury/illness as a consequence of patient related violence Psychological 72% (n = 387) of nurses

18 Impact on nurses Injuries 95 (18%) nurses reported that they had suffered a physical or psychological injury/illness as a consequence of patient related violence Psychological 72% (n = 387) of nurses reported a range of emotions and reactions as a result of their involvement in these episodes PTSD symptoms Professional Only 18 nurses took time off work as a result of an injury/illness Impact on working life e.g. burnout & stress Impact on nursing practice e.g. lack of empathy, decline in quality of care

19 Feeling safe at work (n = 461) I have a martial arts background so feel quite safe Safe or very safe: n = 114, 25% Often qualifying statement Somewhat safe: n = 293, 64% I usually feel safe within the department but am sometimes concerned about walking to my car after an incident...feel unsafe and unsupported... Unsafe: n = 56, 12%...felt safer in active service in the Australian Army... Nurses in regional areas more likely to report feeling unsafe

20 Risk management following Lack of support episodes of violence More than one-third - NOT provided with adequate information, support and follow up following a violent incident More than half NOT provided access to recognised counselling services Nurses in regional areas - less supported than their metropolitan counterparts following exposure to episodes of patient-related violence e.g. access to counselling, rotation in high risk areas Immediate interventions, during the first hours or days after a trauma, can prevent the more serious, long-term complications associated with exposure to traumatic events

21 Risk prevention/minimisation Training - Mandatory - Almost a quarter had never completed aggression minimisation training - 20% did not have access to training in their workplace - three-quarters had not completed regular refresher programs Significant differences in the availability of risk prevention/minimisation measures were found between metropolitan and regional/remote areas. E.g. Nurses in metropolitan areas reported greater access to training, for example Aggression Minimisation ; and security personnel based in the department

22 Future research Recommendations Inequities have been identified between ED nurses working in metropolitan and regional areas and these should be explored further and strategies put in place to rectify these Policy Mandatory requirements embedded in policies should be enforced; Explicit consequences for offenders - and these should be enforced e.g. legal avenues Inequities between metropolitan and regional areas should be addressed.

23 Workplace management Recommendations Approachable, responsive & supportive Workplace education - training accessible & supported Reporting encouraged priority to more serious episodes e.g. injury sustained; staff threatened; repeat offenders Fast tracking Limits on number of visitors Limited access policies Use of single isolation rooms to remove at risk patients Nurses encouraged to take time off especially current shift

24 CRICOS Provider 00109J Publications Pich et al. (2013). Violent behaviour from young adults and the parents of paediatric patients. International Emergency Nursing, 21, Pich et al. (2011). Patient-related violence at triage: A qualitative descriptive study. International Emergency Nursing, 19, Pich et al. (2010). Patient-related violence against emergency department nurses. Nursing and Health Sciences, 12, Systematic review on violence in the ED accepted for publication. For further information please contact: Jacqui Pich School of Nursing & Midwifery The University of Newcastle Callaghan NSW 2308 Australia Jacqueline.Pich@newcastle.edu.au Phone:

25 To CENA for supporting this research and making this study possible CRICOS Provider 00109J

Prevention of occupational violence and aggression

Prevention of occupational violence and aggression 1. Introduction The Australian Nursing & Midwifery Federation (Victorian Branch) [ANMF (Vic Branch)] believes that occupational violence and aggression