Centre conducting review
University of Newcastle Evidence Synthesis Group: a collaborative centre of the Joanna Briggs Institute
Jacqueline Pich RN, BN (Hons I), BSc
Lecturer and PhD candidate
RW 2.14 Richardson Building, School of Nursing and Midwifery, Faculty of Health, The University of Newcastle, Callaghan NSW 2308, Australia
Email for correspondence: Jacqueline.Pich@newcastle.edu.au
Dr Ashley Kable RN, Dip Teach Nurs Ed, Grad Dip Health Serv Mgmt, PhD
Senior Lecturer, Deputy Head of School (Research)
RW 1.34 Richardson Building, School of Nursing & Midwifery, Faculty of Health, The University of Newcastle, Callaghan NSW 2308, Australia.
Commencement date: July 2011 Anticipated completion date: July 2012
The healthcare industry has been identified as one of the most violent workplace sectors, 1 with Emergency Departments ranked as one of the highest-risk areas for such violence. 2 Aggression and violence have been identified as common features of the modern Emergency Department.3 Within this context, nurses have been identified as the occupation at most risk of patient-related violence, with between 60 to 90% of nurses reporting exposure to violence, both verbal and physical.2 Emergency Department nurses have been identified as having the most stressful workplace setting of all nurses 4 and are exposed to a disproportionate amount of violence.5 High levels of verbal abuse and threatening behaviour are reported6, and up to 90% of Emergency Department nurses have experienced physical violence at some point in their careers while all have experienced verbal abuse.7 A recent survey of nurses in the United States identified increasing violence in the Emergency Department as one of their greatest concerns.8
The term violence encompasses a wide range of behaviours 9 from physical assault or direct violence to non-physical forms of violence such as verbal abuse and sexual harassment.10 Studies have found that up to 20% of nurses have experienced intimidation, harassment or assault of a sexual nature.3 Evidence suggests that the term “violence “is frequently used by nurses as an umbrella term to encompass everything from witnessing verbal abuse through to being a victim of physical assault.11
Patients are consistently identified in the literature as being the most common source of violence against nurses, 9 responsible for up to 89% of cases. 12 Other sources of violence include friends and relatives accompanying patients and horizontal violence from other staff members. 3
Verbal abuse has been identified as the most common form of abuse experienced by nurses 13 and has been labelled a global phenomenon.14 It includes rudeness, shouting, sarcasm, swearing, unjustified criticism, ridicule in front of others, threat of personal harm to the person, their family or property, rumour mongering 13 as well as sexual innuendo.15 Of these behaviours, swearing has been singled out as most common form of verbal abuse15, and includes both face-to-face and telephone abuse.16
Physical violence usually co-exists with verbal violence, indicating that it may act as a warning sign for potential or impending physical violence.2 It has been defined as any intentional physical contact, actual or threatened, and does not have to result in an injury to the victim.17 It can also include overt behaviour designed to intimidate or threaten, for example punching a wall or throwing furniture.6 The ready availability of, and easy access to hospital equipment has seen objects such as scissors, syringes, needles and stretcher poles being used as weapons against nurses.14
Violence and assault against nurses is reported to be on the increase 16 and it is widely acknowledged that the true level is unknown due to chronic under-reporting of violent incidents.9 This is true not only in Australia but internationally 3. Estimations of under-reporting range from 20%, 9 to 75% 18 up to 80% 19 even 90% 20 and are referred to as the “dark figure” of workplace violence.13 A culture of silence is said to exist 9 meaning that accurate statistical analysis of the incidence and prevalence of violence has become impossible.3 Reasons cited for failure to report a violent incident include insufficient time; a feeling of resignation that no benefit will come from the process, lack of appropriate support and feedback, the belief that such violence is part of the job;9 fear of reprimand and lack of knowledge in reporting procedures.15
The findings overall indicate that nurses feel unsupported by management in relation to workplace violence.16
Nurses in Emergency Departments in particular have been identified as significantly under-reporting violent incidents, a fact thought to be related to the high levels of violence endemic in these areas.5 These high levels of violence have resulted in a desensitization on the part of many nurses to the point where violence has become an expected and accepted part of their job.21 Verbal and physical abuse are regarded as occupational hazards 12 and there is a rationalisation on the part of many nurses that such violence is unavoidable.21
The types of injuries sustained by nurses as a direct consequence of violent behaviour from patients range from minor, for example scratches, to major including fractures and loss of consciousness, 12 up to extreme cases where nurses have been stabbed and even killed.23 Australian figures for the period 2000 to2002 reported 3, 621 incidents involving patients and physical violence or violent verbal exchange against healthcare staff, and in 5% of these incidents staff injury resulted.24
Even in the absence of physical injury, nurses have been found to experience moderate to severe psychological reactions for up to 12 months following an episode of violence.10 Exposure to violence has been linked to long-term psychological effects, including Post-traumatic Stress Disorder and burnout.25 Despite the seriousness of the consequences, informal discussion or debriefing with colleagues was the most common coping mechanism referred to in the literature.26
Emotional effects reported in the literature include feelings of guilt, self-doubt, feelings of professional incompetence;27 anger, powerlessness, unhappiness, degradation, shame, fear, astonishment, antipathy towards the perpetrator;26 and sleeplessness.16
Nurses have reported feeling more cautious and deriving less satisfaction from their patient-related care as well as being fearful at work. This fear and caution can lead to low morale and lead to a situation where patients are avoided.27 Studies have identified a negative correlation between violence experienced by health care staff and patient-related quality of care.27
The health system is faced with increased costs in terms of sick leave, decreased productivity and staff turnover and attrition, workers compensation pay outs.16 Quantifying the cost of patient-related violence is difficult as it includes intangible items such as loss of morale, difficulties with retention and recruitment of staff, impact on patient care and therapeutic relationships and negative public relations which are difficult to assign a dollar value to.28
The objective of this systematic review is to synthesise the best available evidence on the impact of patient-related violence against nurses working in the Emergency Department.
How does patient-related workplace violence impact on emergency nurses?
Types of participants
The review will consider studies that include nurses working in Emergency Departments.
Phenomena of interest
The phenomenon of interest is patient-related violence, including two key sub-groups young adults (16-25 years) and parents/carers of paediatric patients. 8
Types of outcome
Outcomes considered will include: -
- Frequency of episodes of violence;
- The types of violence - physical and verbal;
- Organisational reporting of episodes of violence;
- Antecedents and risk factors;
- Impact and sequelae of violence: psychological and physical effects;
- Prevention and control measures to manage episodes of violence.
Type of studies
The quantitative component of this review will consider any randomised controlled trials (RCTs) and quasi-randomised controlled trials. In the absence of RCTs, other research designs such as non-RCTs, before and after studies and descriptive quantitative studies will be considered
This review will also consider studies that focus on qualitative data including, but not limited to, designs such as phenomenology, observational studies, grounded theory, ethnography, narrative, action research, discourse analysis, focus groups, interviews and surveys.
In the absence of research studies, other text such as commentaries, opinion papers and reports will be considered in a narrative summary. In addition relevant conference papers and proceedings will be considered as well as existing systemic reviews on the topic.
The exclusion criteria for papers will be: -
- If the setting of the research is in clinical areas other than the Emergency Department;
- Not written in English;
- Those that report violence from sources other than patients;
- Those that report aggression/violence directed at non-nurse hospital staff, for example allied health workers or medical officers.
The search strategy aims to find both published and unpublished studies. Databases will be searched from their inception until present to ensure the search is as broad as possible. A three-step search strategy will be utilised in each component of this review. An initial limited search of MEDLINE and CINAHL will be undertaken followed by analysis of the text words contained in the title and abstract, and of the index terms used to describe article. A second search using all identified keywords and index terms will then be undertaken across all included databases. Thirdly, the reference list of all identified reports and articles will be searched for additional studies.
Studies identified through the database searches will be assessed for their relevance to the review, based initially on abstract and title. Copies of papers will be retrieved for those studies that appear to meet the inclusion criteria and further assessed for suitability.
The databases to be searched include:
- Mosby's Index
- Joanna Briggs Library of Systematic Reviews
- The Cochrane Library of Systematic Reviews
To finalise the strategy, a search for unpublished studies using Google Scholar, Mednar and Proquest will be undertaken to locate any relevant policies, government reports, dissertations, theses and conference proceedings.
Initial Search Terms
The following search terms will be used: -
- Emergency Department or Emergency Service or ED;
- Accident and Emergency or A & E or Triage;
- Violence or Aggression or Assault or Abuse;
- Patient or Patient-Related or Client;
Assessment of methodological quality
Critical appraisal tools
Quantitative papers selected for retrieval will be assessed by two independent reviewers for methodological validity prior to inclusion in the review using standardised critical appraisal instruments from the Joanna Briggs Institute Meta Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI) (Appendix I).
Qualitative papers selected for retrieval will be assessed by two independent reviewers for methodological validity prior to inclusion in the review using standardised critical appraisal instruments from the Joanna Briggs Institute Qualitative Assessment and Review Instrument (JBI-QARI) (Appendix I).
Textual papers selected for retrieval will be assessed by two independent reviewers for authenticity prior to inclusion in the review using standardised critical appraisal instruments from the Joanna Briggs Institute Narrative, Opinion and Text Assessment and Review Instrument (JBI-NOTARI) (Appendix I).
Any disagreements that arise between the reviewers will be resolved through discussion, or with a third reviewer.
Assessing the grey literature
Literature identified during a search of the grey literature will be categorised according to the type of study (quantitative, qualitative or narrative text) and assessed accordingly.
Quantitative data will be extracted from papers included in the review using the standardised data extraction tool from JBI-MAStARI (Appendix II).
Qualitative data will be extracted from papers included in the review using the standardised data extraction tool from the Joanna Briggs Institute Qualitative Assessment and Review Instrument JBI-QARI (Appendix II).
Textual data will be extracted from papers included in the review using the standardised data extraction tool from JBI-NOTARI (Appendix II).
The data extracted will include specific details about the interventions, populations, study methods and outcomes of significance to the review question and specific objectives.
Quantitative papers will, where possible be pooled in statistical meta-analysis using the Joanna Briggs Institute Meta Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI). All results will be subject to double data entry. Odds ratio (for categorical data) and weighted mean differences (for continuous data) and their 95% confidence intervals will be calculated for analysis. Heterogeneity will be assessed using the standard Chi-square. Where statistical pooling is not possible the findings will be presented in narrative form.
Qualitative research findings will, where possible be pooled using the Qualitative Assessment and Review Instrument (JBI-QARI). This will involve the aggregation or synthesis of findings to generate a set of statements that represent that aggregation, through assembling the findings (Level 1 findings) rates according to their quality, and categorising these findings on the basis of similarity in meaning (Level 2 findings). These categories are then subjected to a metasynthesis in order to produce a single comprehensive set of synthesised findings (Level 3 findings) that can be used as a basis for evidence-based practice. Where textual pooling is not possible the findings will be presented in narrative form.
Textual papers will, where possible be pooled using the Narrative, Opinion and Text Assessment and Review Instrument (JBI-NOTARI). This will involve the aggregation or synthesis of conclusions to generate a set of statements that represent that aggregation, through assembling the conclusions to generate a set of statements that represent that aggregation, through assembling and categorising these conclusions on the basis of similarity in meaning. These categories are then subjected to a metasynthesis in order to produce a single comprehensive set of synthesised findings that can be used as a basis for evidence-based practice. Where textual pooling is not possible the conclusions will be presented in narrative form.
Conflicts of interest
The authors declare no conflicts of interest exist.
This systematic review is being conducted as part of the PhD studies of Jacqueline Pich.
1. Perrone, S. Violence in the workplace: Research and public policy series no.22. Canberra: Australian Institute of Criminology. 1999; no.22.
2. Lau, J., Magarey, J. & McCutcheon, H. Violence in the ED: A literature review. Australasian Emergency Nursing Journal. 2004;
3. Ryan, D., & Maguire, J. Aggression and violence - a problem in Irish Accident and Emergency departments? Journal of Nursing Management. 2006; 14(2): 106-115.
4. Donnelly, C. Tackling violence head on. Emergency Nurse. 2006; 13(10): 5.
5. Holleran, R. S. Preventing staff injuries from violence. Journal of Emergency Nursing. 2006; 32(6), 523-524.
6. Winstanley, S., & Whittington, R. Aggression towards health care staff in a UK general hospital: variation among professions and departments. Journal of Clinical Nursing. 2004; 13(1), 3-10.
7. Kennedy, M. P. Violence in emergency departments: under-reported, unconstrained, and unconscionable. The Medical Journal of Australia. 2005; 183(7), 362-365.
8. Keough, V. A., Schlomer, R. S., & Bollenberg, B. W. Serendipitous findings from an Illinois ED nursing educational survey reflect a crisis in emergency nursing. Journal of Emergency Nursing. 2003; 29(1), 17-22.
9. Lyneham, J. Violence in New South Wales emergency departments. Australian Journal of Advanced Nursing. 2000; 18(2), 8-17.
10. Gerberich, S. G., Church, T. R., McGovern, P. M., Hansen, H. E., Nachreiner, N. M., Geisser, M. S., et al. An epidemiological study of the magnitude and consequences of work related violence: the Minnesota Nurses' Study. Occupational and Environmental Medicine. 2004; 61(6), 495-503.
11. Ferns, T. Terminology, stereotypes and aggressive dynamics in the accident and emergency department. Accident and Emergency Nursing. 2005; 13(4), 238-246.
12. McKinnon, B., & Cross, W. Occupational violence and assault in mental health nursing: a scoping project for a Victorian Mental Health Service. International Journal of Mental Health Nursing. 2008; 17(1), 9-17.
13. Farrell, G. A., Bobrowski, C., & Bobrowski, P. Scoping workplace aggression in nursing: findings from an Australian study. Journal of Advanced Nursing. 2006; 55(6), 778-787.
14. Ferns, T. Violence in the accident and emergency department: An international perspective. Accident and Emergency Nursing. 2005; 13(3), 180-185.
15. Crilly, J., Chaboyer, W., & Creedy, D. Violence towards ED nurses by patients. Accident and Emergency Nursing. 2004; 12(2): 67-73.
16. Jackson, D., Clare, J., & Mannix, J. Who would want to be a nurse? Violence in the workplace—a factor in recruitment and retention. Journal of Nursing Management. 2002; 10(1), 13-20.
17. Victorian Government. Occupational violence in nursing: An analysis of the phenomenon of code grey/black events in four Victorian hospitals. 2005; Melbourne, Victoria: Big Print.
18. Jones, J., & Lyneham, J. Violence: part of the job for Australian nurses? Australian Journal of Advanced Nursing. 2000; 18(2), 27-32.
19. Phillips, S. Countering workplace aggression: an urban tertiary care institutional exemplar. Nursing Administration Quarterly. 2007; 31(3), 209-218.
20. Mayhew, C. & Chappell, D. Violence in the workplace. The Medical Journal of Australia. 2005; 183(7), 346-347.
21. Ray, M. M. The dark side of the job: violence in the ED. Journal of Emergency Nursing. 2007; 33(3): 257-261.
22. McKinnon, B., & Cross, W. Occupational violence and assault in mental health nursing: a scoping project for a Victorian Mental Health Service. International Journal of Mental Health Nursing. 2008; 17(1), 9-17.
23. Lynch, J., Appelboam, R., & McQuillan, P. J. Survey of abuse and violence by patients and relatives towards intensive care staff. Anaesthesia. 2003; 58(9), 893-899.
24. Benveniste, K. A., Hibbert, P. D., & Runciman, W. B. Violence in health care: the contribution of the Australian Patient Safety Foundation to incident monitoring and analysis. Medical Journal of Australia. 2005; 183(7), 348-351.
25. Camerino, D., Estryn-Behar, M., Conway, P. M., van Der Heijden, B. I., & Hasselhorn, H. M. Work-related factors and violence among nursing staff in the European NEXT study: a longitudinal cohort study. International Journal of Nursing Studies. 2008; 45(1), 35-50.
26. Astrom, S., Karlsson, S., Sandvide, A., Bucht, G., Eisemann, M., Norberg, A., et al. Staff's experience of and the management of violent incidents in elderly care. Scandinavian Journal of Caring Sciences. 2004; 18(4), 410-416.
27. Arnetz, J. E., & Arnetz, B. B. Violence towards health care staff and possible effects on the quality of patient care. Social Science and Medicine. 2001; 52(3), 417-427.
28. Hunter, M., & Carmel, H. The cost of staff injuries from inpatient violence. Hospital and Community Psychiatry. 1992; 43(6), 586-588.
Appendix I - JBI Critical Appraisal instruments
JBI-MAStARI Appraisal Instruments
JBI QARI Appraisal instrument
JBI NOTARI Appraisal instrument
Appendix II - JBI Data extraction instruments
JBI MAStARI data extraction instrument
JBI QARI data extraction instrument
JBI Notari Data Extraction Instrument