A qualitative meta-synthesis of emergency department staff experiences of violence and aggression

Highlights

• ED staff experienced violence and aggression as an inevitable part of the job.

• Staff appraisals of violent behaviour influenced their tolerance towards patients.

• Occupying role of victim when caring for patients created “wounds”.

• Consistent organisational response to violence and aggression is imperative.

Abstract

Introduction

Patient and visitor violence or aggression against healthcare workers in the Emergency Department (ED) is a significant issue worldwide. This review synthesises existing qualitative studies exploring the first-hand experiences of staff working in the ED to provide insight into preventing this issue.

Method

A meta-ethnographic approach was used to review papers.

Results

Four concepts were identified: ‘The inevitability of violence and aggression’; ‘Staff judgments about why they face violence and aggression’; ‘Managing in isolation’; and ‘Wounded heroes’.

Discussion

Staff resigned themselves to the inevitability of violence and aggression, doing this due to a perceived lack of support from the organisation. Staff made judgements about the reasons for violent incidents which impacted on how they coped and subsequently tolerated the aggressor. Staff often felt isolated when managing violence and aggression. Key recommendations included: Staff training in understanding violence and aggression and clinical supervision.

Conclusion

Violence and aggression in the ED can often be an overwhelming yet inevitable experience for staff. A strong organisational commitment to reducing violence and aggression is imperative.

Introduction

Violence against healthcare workers has been considered a significant problem in the United Kingdom (UK) and worldwide [1], [2]. The latest UK statistics demonstrated that there were 70,555 total reported assaults on National Health Service (NHS) staff in the last year [3]. A systematic literature review of patient and visitor violence in general hospitals from multiple countries showed that on average 50 per cent of healthcare staff reported experiencing verbal abuse and 25 per cent had experienced physical abuse [4].

Violence and aggression against staff has been documented as a significant problem in EDs specifically [5]. In one study conducted in Australia, 70 per cent of nurses working in two EDs reported that they had experienced violence in the previous five months [6]. One recent review of studies across 18 countries showed significant discrepancy between staff reports of the incidence of both verbal (21–82 per cent) and physical aggression (13–79 per cent) in the ED [7]. This suggests that rates of verbal and physical aggression in the ED vary greatly internationally.

Research has highlighted the significant consequences of patient and visitor violence against staff. Experiencing violence and aggression can lead to staff responses including anger, fear or anxiety, post-traumatic stress ‘symptoms’, guilt, self-blame and shame [8]. Direct physical injury is also a common consequence of assaults on staff [4]. Violence and aggression against ED nurses reduces work productivity and quality of patient care [9], which in turn increases the costs to the organisation [10], and possible recrtuiment problems [11].

Nurses are subjected to verbal and physical abuse so frequently in some EDs that it has now arguably become an accepted part of the job [12]. The normalisation of violence in the workplace impacts on incident reporting. Chronic under-reporting of violent incidents in EDs has been well-documented both in Australia and worldwide, with reasons for under-reporting including: a lack of policy and procedure; feeling discouraged to report by management; a lack of follow-up [13]; fear of being negatively judged; fear of vendetta, and lack of reporting systems [7]. Pich et al. [12] have argued that the normalisation of patient and visitor violence can become embedded within organisational culture which inhibits the implementation of effective preventative strategies.

In the UK, preventative strategies have been environmentally focussed, such as alarms, security presence or metal detectors. Another strategy adopted in several countries is the zero tolerance policy, which stipulate that specific actions or behaviours will not be accepted; however, the effectiveness of this approach is questionable [14]. In fact, few studies exist which assess the effectiveness of any interventions aimed at reducing violence in EDs [15], with reviews being inconclusive due to design issues, difficulty defining violence and a paucity of papers [16].

There are also few studies examining first-hand experiences of healthcare staff dealing with violence and aggression in the ED, despite such accounts having the potential to suggest novel ways of preventing violence. Existing quantitative reviews in this area have focused on simply describing the phenomenon [5], whereas qualitative methodologies can be useful in exploring perspectives [17]. However, there are no known qualitative reviews exploring the experience of violence and aggression in staff working in the ED. Synthesising studies across countries and contexts can offer greater understanding about the common factors which influence the experience of violence and aggression in the ED. The aim of this review is therefore, to synthesise qualitative studies exploring staff experiences of violence and aggression in EDs.