Violence,aggression and physical assault in healthcare settings

Violence,aggression and physical assault in healthcare settings Ferns T (2006) Violence, aggression and physical assault in healthcare settings. Nursing Standard. 21, 13, 42-46. Date of acceptance: August 10 2006. Summary All healthcare professionals are at risk from violent and aggressive patients, however, it has been found that nurses are at particular risk. The actual incidence is difficult to determine because the definition of what constitutes a physical assault or a violent event is vague. This article considers how the terms violence, aggression and physical assault are conceptualised in the healthcare setting and suggests that nursing staff need to identify and act on any incident that compromises their personal safety. Author Terry Ferns is senior lecturer, University of Greenwich, School of Health and Social Care, Department of Acute and Continuing Care, London. Email: T.Ferns@gre.ac.uk Keywords Challenging behaviour; Nurse patient relations; Occupational health and safety; Violence These keywords are based on the subject headings from the British Nursing Index. This article has been subject to double-blind review. For author and research article guidelines visit the Nursing Standard home page at www.nursing-standard.co.uk. For related articles visit our online archive and search using the keywords. ACCORDING TO the National Audit Office (2003), NHS staff in the UK reported 116,000 violent or abusive incidents during 2000/2001. Consequently, developing strategies to minimise the impact of violence or abuse in healthcare settings is extremely important. Leather (2002) states that all healthcare professionals are at risk of exposure to some form of patient aggression, and that nurses are particularly at risk, with 100 per cent experiencing at least one incident during their career. Problems of definition The Oxford English Dictionary (2004) defines violence as actions using physical force intended to hurt, damage or kill. However, a major difficulty when examining incidents of violence experienced by nurses is that there is no standardised, universal definition of violence (Sommargren 1994). The Department of Health (DH) uses the following definition for physical assault: The intentional application of force to the person of another without lawful justification, resulting in physical injury or personal discomfort (Counter Fraud and Security Management Service (CFSMS) Division 2003). However, Poster and Ryan (1993) state that despite the fact that assault may have a legal definition, the term is often used interchangeably with physical aggression or physical violence. Violence is a subjective phenomenon and therefore people interpret it in different ways. Interpretations of what constitutes violence range from verbal abuse to life-threatening injury. The lack of a standardised definition means that it is difficult to compare research studies that relate to violence, and this has led to an inability to clarify the incidence and nature of violence experienced by nurses (Sommargren 1994). Some of the reasons why studies are difficult to compare with each other are listed in Box 1. Studies examining interpersonal conflict in healthcare facilities use differing baseline definitions of violence, aggression and physical and non-physical assault. They have also been conducted in different countries, cultures and specialties and used a wide variety of research instruments. Authors highlight that a lack of rigorous research, inconsistent definitions of violence, methodological concerns such as small sample sizes and few control groups, inconsistencies in sampling generalisations, and publications not having been subjected to peer review limit efforts to address the problem of violence in the healthcare setting and the degree to which the data offered can be trusted (Merchant and Lundell 2001, McKenna et al 2003). In regard to standardised definitions, Scott (1992) states that because there are so many interpretations of the term aggression, it has become useless for the purposes of scientific analysis. Nurse researchers need to develop an understanding of what is meant by violence and aggression that is in keeping with the average nurse s use of these terms (Farrell 1997). 42 december 6 :: vol 21 no 13 :: 2006 NURSING STANDARD

Whykes (1994) insists that defining violence is an essential first step for those involved in the investigation, management and prevention of violence at work. The key to the prevention of violent incidents lies in understanding the phenomenon of violence and having a clear definition of what constitutes a violent act. The role of intent Generally, nurses do not consider patients such as the one described in Box 2 as having committed a crime. Patients who are physically aggressive because of physical pain, distress or mental health problems do not mean to be aggressive and there are extenuating circumstances for the aggression (Budd 1999). Anecdotally, nurses do not feel that confused, demented patients or confused, anaesthetised patients are violent, particularly if the degree of force or threat is perceived as minimal because of age, illness or weakness, or if there is no perceived intent. Eysenck (2002) cites the example of a person who slips on ice and crashes into someone accidentally. That person would not be regarded as aggressive or violent because of the perceived lack of intent and hence the victim may not classify this experience as a physical assault. There is clearly a major difference between malicious, gratuitous violence inflicted against nursing staff and disorientated, unco-ordinated, unintentional arm-waving by patients that has resulted in physical injury. However, there is a common factor. In both cases, the nurse can be hurt. Despite this, if nurses are physically harmed by a confused patient they will probably not consider that they have been assaulted. Violence that occurs for clinical reasons should be differentiated from incidents where there is conscious malicious intent. However, nurses still require skills in the prevention of unintentional aggression. For example, nurses who physically BOX 1 Reasons why it is difficult to compare studies relating to violence and aggression within healthcare facilities The interchangeable use of the terms abuse and assault. The variety of time periods considered, for example, studies have been conducted retrospectively over six months, one year and five years. Possible bias in the construction of some surveys. Variations in the characteristics of study sites. Under-reporting and a lack of common data-collection standards in official reports. (Adapted from Wells and Bowers 2002) NURSING STANDARD BOX 2 Clinical example An older person with Alzheimer s disease who is confused and disorientated suddenly lashes out and hits a nurse while receiving personal care. Has the nurse experienced violence, aggression or physical assault? Does unintentional aggression warrant formal reporting? restrain confused, aggressive, semi-anaesthetised patients are legally vulnerable if they have not been trained in this skill. Nurses need to adopt a zero-tolerance approach to all incidents of aggression, not as a punitive measure against confused patients but to equip themselves to care safely for such patients. Hence, if nurses are working regularly with patients with an identified higher risk of displaying unintentional aggression, they need to be equipped with the necessary skills to care for such patients. This strategy can only begin when nursing staff identify and report all incidents that are a risk to their personal safety. In so doing they will aid the implementation of risk-minimisation strategies. There is a need for a revised classification of terminology in health care. Mullen (1997) identifies that the majority of articles relating to workplace violence deal with intentional acts of harm. He conceptualises occupational violence as violence related primarily to the nature or location of one s work. In law, individuals are deemed to have committed a criminal offence only if they can be shown to have intended so to do (Harrower 1998). However, nurses frequently comment that they have been hurt by a confused patient, but that the patient was aware of what he or she was doing at the specific time the incident took place, that is, although a patient may be confused he or she may experience periods of lucidity, which complicates the case even further. In this situation the following questions need to be asked: Are patients confused or not? Is there intent or not? What can be proved? What should be reported? Eysenck (2002) emphasises that it is important to distinguish between aggression that is intended to hurt someone (hostile aggression) and aggression designed to obtain a desired outcome or object (instrumental aggression). Nurses may further categorise violence by the degree of force, significance of the threat, age of the patient or his or her mental state at the time of the incident and december 6 :: vol 21 no 13 :: 2006 43

in so doing may become desensitised to repeated exposure to minor assault (Whykes 1994). For example, paediatric nurses may ignore being scratched or bitten by children, or adult nurses may ignore threats by patients who are too ill or too old to follow up their threats. As stated earlier, there are many reasons why nurses do not report incidents, for example, the patient was old, confused, unwell, or did not really mean it. However, if the nursing profession is to gain an understanding of nurses experiences of physical aggression and violence, nurses need to document the specific nature of the incident. Is nursing a dangerous profession? Much of the research literature examining interpersonal conflict in healthcare facilities portrays a bleak picture. Williams (1996) states that there are documented incidents in hospital settings of sexual assault, arson, battery, robbery, kidnapping, homicide, theft and bomb threats. Figures suggest that healthcare workers are four times more likely to experience workplace violence than the general population (Budd 1999). The number of injuries sustained by nurses as a result of violence is estimated to be higher than workplace injures reported in high-risk occupations such as mining, forestry or heavy construction (Love and Hunter 1996, Nolan et al 1999). However, it is important to consider BOX 3 Four categories of workplace aggression Type I: The perpetrator has no legitimate relationship with the targeted organisation or its employees and enters the work environment to commit a criminal act. In the healthcare context this person would be, for example, a car thief who specifically enters the facility to commit a crime. Type II: The assailant has a legitimate relationship with the organisation and commits an act of violence while being served by that organisation. This individual could be a patient, relative, friend or visitor. The incidents could be both intentional or unintentional. However, this group can also include a rowdy person under the influence of alcohol in the accident and emergency department. The key point is that the person believes he or she has a legitimate reason for entering the healthcare facility. Type III: The offender is typically a current or former employee (an insider) who targets a co-worker or supervisor for perceived wrongdoing. Importantly for the nursing profession this group can include staff involved in bullying or harassment. It can also refer to current employees with little respect for the employing organisation. Type IV: The perpetrator has an ongoing or previous legitimate relationship with an employee of the organisation. This group, could, for example, include employees partners who engage in domestic violence. (LeBlanc and Barling 2004) the context of the working environment and such statistics and reports need to be treated with caution. There is a significant difference between the risk of assault to mental health nurses practising in acute psychiatric admission units and the average nurse working in a discharge lounge, GP surgery or general medical or surgical ward. It is the context in which the nurse practises that is important. Nurses are involved in a high-risk occupation when it comes to violence but, outside of areas such as mental health and accident and emergency, serious physical assaults remain uncommon. In addition, more nursing staff may report that they have been assaulted than construction workers, but many more construction workers than nursing staff will die as a result of workplace injuries because of the nature of their occupations. In 2002/2003, 71 fatal injuries of construction workers occurred, which is 31 per cent of the total number of workplace fatalities (226) in Great Britain. In 2001/2002 there were 80 fatal injuries and 4,480 major injuries were sustained by workers in the construction industry. The provisional number of workers fatally injured in 2005/2006 was 212, a decrease of 5 per cent from 2004/2005 when the number of workers fatally injured was 223 (Health and Safety Commission 2003). A strategy for classifying violent individuals LeBlanc and Barling (2004) have examined the factors involved in violent or aggressive incidents and differentiate workplace aggression into four categories based on the California Division of Occupational Safety and Health (CAL-OSHA) (1995) classification (Box 3). Islam et al (2003) identified that 99 per cent of healthcare workers responding to their survey experienced type II conflict. The literature supports the view that nurses are more likely to experience aggression from patients to whom they give direct care (Dalphond et al 2000, O Connell et al 2000, Hesketh et al 2003), and visitors, relatives or friends, rather than other members of the multidisciplinary team (Rippon 2000) or intruders (Williams 1996). NHS Security Management Service The DH funded the development of the NHS Security Management Service (SMS), which is part of the CFSMS. The CFSMS has responsibility for matters related to the management of security in the NHS. It recognises the urgent need to tackle violence in the NHS and its aim is simple to protect the NHS so it can better protect the public s health 44 december 6 :: vol 21 no 13 :: 2006 NURSING STANDARD

(CFSMS Division 2003). The CFSMS has a wide remit with a specific direction to implement a national incident reporting system for recording physical assaults, a consistent local reporting system for non-physical incidents, and the introduction of clear and legally based definitions. As a consequence, the secretary of state for health has introduced baseline directions, which include defining physical assault as: The intentional application of force to the person, without lawful justification, resulting in physical injury or personal discomfort (CFSMS Division 2003). This definition will help to clarify intentional violence or aggression but does little to consider aggression directed at general nurses from confused, hypoxic patients lacking orientation or rationality and complaining of pain or discomfort. Winstanley and Whittington (2002) have identified the link between confusion, psychosis or the effects of prescribed or illegal drugs and the increased risk of violence to general nursing staff. Government strategy appears to promote the idea of fortifying healthcare facilities and prosecuting offenders. Although this seems, to some extent, reasonable, it does little to address the day-to-day low level incidents of violence and aggression that general nurses may encounter. Technically, with regard to the definition of the CFSMS Division, nurses have not been physically assaulted if the application of force is deemed unintentional. A list of factors that may predispose BOX 4 Factors that may predispose patients to becoming violent Head injuries, cerebrovascular accidents, cerebral pathology, organic brain dysfunction or clinical brain injury. Hypoxia. Endocrine disorders hypo or hyperglycaemia. Seizures, frontal, temporal or limbic epilepsy. Psychiatric disorders, hallucinations, depression, anxiety, stress reactions or personality disorders. History of post-traumatic stress syndrome. Side effects of prescribed medication. Intoxication. Drug overdose. Drug or alcohol withdrawal. Age considerations, senility, dementia, adolescence, childhood disorders conduct disorders, hyperkinetic disorders, autism or learning disability. (Whykes 1994, Drury 1997, Wing et al 1998, Saines 1999, Keely 2002) patients to becoming potentially violent is provided in Box 4. The key point is that nursing staff are much more likely to be hurt by patients who present with combinations of these factors. Nurses who are injured by patients should be reporting such incidents to prevent colleagues References Budd T (1999) Violence at Work: Findings from the British Crime Survey. Home Office, London. California Division of Occupational Safety and Health (1995) Injury and Illness Prevention Model Program for Workplace Security. CAL-OSHA, Oakland CA. Counter Fraud and Security Management Service Division (2003) Protecting your NHS: A Professional Approach to Managing Security in the NHS. www.cfsms.nhs.uk/doc/sms. general/sms.strategy.pdf (Last accessed: November 23 2006.) Dalphond D, Gessner M, Giblin E, Hijazzi K, Love C (2000) Violence against emergency nurses. Journal of Emergency Nursing. 26, 2, 105. Department of Health (2002) 2000/2001 Survey of Reported Violent or Abusive Incidents, Accidents Involving Staff and Sickness Absence in NHS Trusts and Health Authorities in England. The Stationery Office, London. Drury T (1997) Recognizing the potential for violence in the ICU. Dimensions of Critical Care Nursing. 16, 6, 314-323. Eysenck MW (2002) Simply Psychology. Second edition. Psychology Press, Taylor and Francis Group, London. Farrell GA (1997) Aggression in clinical settings: nurses views. Journal of Advanced Nursing. 25, 3, 501-508. Harrower J (1998) Applying Psychology to Crime. Hodder and Stoughton, London. Health and Safety Commission (2003) 25,000th Visitor to Construction Safety Roadshow. HSC press release C050:03. www.hse.gov.uk/press/2003/c03050.htm (Last accessed: November 23 2006.) Hesketh KL, Duncan SM, Estabrooks CA et al (2003) Workplace violence in Alberta and British Columbia hospitals. Health Policy. 63, 3, 311-321. Islam SS, Edla SR, Mujuru P, Doyle EJ, Ducatman A (2003) Risk factors for physical assault: state-managed workers compensation experience. American Journal of Preventive Medicine. 25, 1, 31-37. Keely BR (2002) Recognition and prevention of hospital violence. Dimensions of Critical Care Nursing. 21, 6, 236-241. Leather P (2002) Workplace violence: scope, definition and global context. In Cooper C, Swanson N (Eds) Workplace Violence in the Health Sector. International Labour Organization, Geneva, 3-18. LeBlanc MM, Barling J (2004) Workplace aggression. Current Directions in Psychological Science. 13, 1, 9-12. Love CC, Hunter ME (1996) Violence in public sector psychiatric hospitals. Benchmarking nursing staff injury rates. Journal of Psychosocial Nursing and Mental Health Services. 34, 5, 30-34. McKenna BG, Poole SJ, Smith NA, Coverdale JH, Gale CK (2003) A survey of threats and violent behaviour by patients against registered nurses in their first year of practice. International Journal of Mental Health Nursing. 12, 1, 56-63. NURSING STANDARD december 6 :: vol 21 no 13 :: 2006 45

from being accidentally bitten, scratched, punched or kicked in similar circumstances in the future. Physical violence should not be tolerated at work regardless of whether the aggression is from malicious intruders, dependent patients or distraught relatives just as psychological aggression from bullying colleagues should not be tolerated. Furthermore, it can be speculated that general nursing staff who work with patients presenting with the conditions listed in Box 4 are more likely to be caring for agitated, uncompliant individuals (as a manifestation of the illness). Nurses, therefore, may be at greater risk of sustaining physical injuries during, for example, manual handling procedures. Changing the position of an uncompliant patient may be dangerous for nursing staff because aggressive patients may resist nursing intervention and may indirectly hurt nursing staff through accidental injury rather than malicious assault. General nursing staff should be able to raise concerns about their personal safety whenever they are susceptible to being hurt at work. In many cases the emphasis should be on staff safety rather than aggressor prosecution. Injuries to all staff, regardless of intent, must be documented and nursing staff need to be clear that the majority of incidents resulting in staff injury are predictable and therefore preventable. The nurse should ask the following questions: Am I the victim of violence? Am I the victim of aggression? Am I the victim of physical assault? However, perhaps the first question should be whether the nurse has been hurt. Conclusion Violent or aggressive outbursts may be a normal part of the experience of illness. Nurses have chosen to care for vulnerable people who may be angry, afraid, self-abusive or in pain. Violent or aggressive outbursts are, for some, part of the reality of the healthcare experience, as is unintentional assault from confused and disorientated people. However, the nursing profession has to acknowledge that the safety of its members is a priority. Defining and classifying the various potential dangers that general nursing staff face would allow the profession to develop workable strategies to minimise risk. Any occupation whose individual members are exposed regularly to experiences that are potentially damaging or distressing has a moral and legal responsibility to protect them NS References continued Merchant JA, Lundell JA (2001) Workplace violence intervention research workshop, April 5-7, 2000, Washington, DC. Background, rationale, and summary. American Journal of Preventive Medicine. 20, 2, 135-140. Mullen PE (1997) A reassessment of the link between mental disorder and violent behaviour, and its implications for clinical practice. Australian and New Zealand Journal of Psychiatry. 31, 1, 3-11. National Audit Office (2003) A Safer Place to Work: Protecting NHS Hospital and Ambulance Staff from Violence and Aggression. NAO, London. Nolan P, Dallender J, Soares J, Thomsen S, Arnetz B (1999) Violence in mental health care: the experiences of mental health nurses and psychiatrists. Journal of Advanced Nursing. 30, 4, 934-941. O Connell B, Young J, Brooks J, Hutchings J, Lofthouse J (2000) Nurses perceptions of the nature and frequency of aggression in general ward settings and high dependency areas. Journal of Clinical Nursing. 9, 4, 602-610. Oxford English Dictionary (2004) Sixth edition. Oxford University Press, Oxford. Poster E, Ryan J (1993) Violence at work: at risk of assault. Nursing Times. 89, 23, 30-32. Rippon TJ (2000) Aggression and violence in health care professions. Journal of Advanced Nursing. 31, 2, 452-460. Saines JC (1999) Violence and aggression in A&E: recommendations for action. Accident and Emergency Nursing. 7, 1, 8-12. Scott JP (1992) Aggression: functions and control in social systems. Aggressive Behavior. 18, 1-20. Sommargren CE (1994) Violence as an occupational hazard in the acute care setting. American Association of Critical Care Nursing Clinical Issues in Critical Care Nursing. 5, 4, 516-522. Wells J, Bowers L (2002) How prevalent is violence towards nurses working in general hospitals in the UK? Journal of Advanced Nursing. 39, 3, 230-240. Whykes T (1994) Violence and Health Care Professionals. Chapman and Hall, London. Williams MF (1996) Violence and sexual harassment: impact on registered nurses in the workplace. American Association of Occupational Health Nurses Journal. 44, 2, 73-77. Wing JK, Marriott S, Palmer C, Thomas V (1998) The Management of Imminent Violence: Clinical Practice Guidelines to Support Mental Health Services. Occasional Paper OP41. Royal College of Psychiatrists, London. Winstanley S, Whittington R (2002) Violence in a general hospital: comparison of assailant and other assault-related factors on accident and emergency and inpatient wards. Acta Psychiatrica Scandinavica. 106, 412, 144-147. 46 december 6 :: vol 21 no 13 :: 2006 NURSING STANDARD