Nurses’ experiences of workplace violence in psychiatric nursing: a qualitative review protocol

Abstract

Objective: 

The objective of this review is to explore nurses’ experiences of workplace violence in the field of psychiatric nursing.

Introduction: 

Although violent incidents are more common in psychiatric inpatient settings (e.g., psychiatric hospitals), violence has increased in psychiatric outpatient settings (e.g., mental health centers and day centers). Exposure to workplace violence can impact nurses’ resilience and levels of burnout. However, there is a lack of qualitative evidence specifically identifying nurses’ experiences of workplace violence in the context of psychiatric nursing. This review will appraise and synthesize available evidence related to nurses’ experiences of workplace violence in the context of psychiatric nursing.

Inclusion criteria: 

This review will consider studies that relate to nurses working in the field of psychiatric nursing in mental health settings worldwide. The specific inclusion criteria are as follows: qualitative studies that explore the experiences of nurses regarding workplace violence published in English, Finnish, or Swedish with no publication date limitations.

Methods: 

PubMed, CINAHL, PsycINFO, PsycARTICLES, Scopus, Web of Science, ProQuest, and the Directory of Open Access Journals will be searched to identify published studies. ProQuest Dissertations and Theses, Google Scholar, and MedNar will be searched to identify unpublished studies. The review will be conducted in accordance with the JBI methodology for systematic reviews of qualitative evidence. Qualitative research findings will be pooled using JBI System for the Unified Management, Assessment, and Review of Information with the meta-aggregation approach. The ConQual approach will be used to assess confidence in the findings.

Introduction

According to the World Health Organization (WHO), violence is defined as “the intentional use of physical force or power, threatened or actual, against oneself, another person, group, or community that either results in or has a high likelihood of resulting in injury, death, psychological harm, maldevelopment, or deprivation.”^1(p.5) Violence can appear in different forms, such as physical violence (e.g., kicking, pushing, biting) or psychological violence (e.g., verbal abuse, bullying, harassment).² Violence can also occur in workplaces.³ The International Labour Office has defined workplace violence as “incidents where employees are abused, threatened or assaulted in circumstances related to their work (including commuting to and from work) involving an explicit or implicit challenge to their safety, well-being or health.”^3(p.3) Workplace violence can be divided into internal and external violence according to the perpetrator: internal violence occurs between workers, whereas external violence takes place between workers and someone outside of the workplace.⁴

Violence may occur in different kinds of health care settings.² Therefore, health care professionals, such as nurses, are potentially at risk of workplace violence. This risk has increased year on year and is a worldwide problem. An estimated 8% to 38% of nursing staff experience some kind of violence during their career.² Violent incidents are more common in psychiatric inpatient settings (e.g., psychiatric hospitals) than in psychiatric outpatient settings (e.g., mental health centers, day centers) or other nursing fields.⁵ However, violence has also increased in psychiatric outpatient settings.⁶ Previous studies have indicated that approximately 40% to 65% of nurses working in the field of psychiatric nursing have been exposed to workplace violence.^5,7-9 When considering reasons for this increased risk of violent incidents in the field of psychiatric nursing, it has been proposed that biological and psychological factors influence a patient's violent behavior, and severe psychiatric disorders, such as psychosis, and substance abuse increase this risk.¹⁰ It has also been suggested that cultural taboos, values, and sensitivity affect the likelihood of violence and lead to intercountry differences in violent exposure.^11,12 For example, physical violence and sexual harassment are more common in the Anglo region, whereas psychological violence occurs more often in the Middle East.¹¹ On the other hand, nurses’ attitudes towards patient aggression can vary across countries.¹² Individual factors, such as sex, age, and working experience, and organizational factors, such as workload and lack of resources, may also influence the occurrence of violence.¹³ Workplace violence is a risk against occupational well-being and can harm the quality of care.¹⁴

Experiences can be understood as a person's subjective and individual perceptions of the surrounding world.¹⁵ Based on this constructivist paradigm of diversity and subjectivity of reality,¹⁵ and the definitions of violence¹ and workplace violence³ mentioned above, it is justifiable to propose that exposures to violence are also subjective experiences. Individual experiences are linked to the consequences of violence because they can result in physical and psychological consequences.⁴ Physical injuries can be considered direct consequences of physical violence, whereas psychological consequences, such as emotional reactions, are indirect consequences.¹³ Psychological consequences can cause long-term effects, such as exhaustion, insomnia, or depression, and the quality as well as the duration of these symptoms can vary significantly.¹⁶ Ability to handle these symptoms and psychological strain is related to a person's individual ability to adapt to stress and adversity (i.e., resilience), and this may explain why some people handle psychological strain more effectively than others.¹⁷ For example, a study by Rees et al.¹⁸ revealed that workplace violence impacts nurses’ resilience and levels of burnout. Conversely, the theory of adaption proposes that nurses adapt cognitively to their experiences of workplace violence by finding meaning, gaining mastery, and enhancing self.¹⁹

Undoubtedly, violence can have different consequences and it is important to consider how the victims, in this case nurses, experience the situation and handle it on a psychological level. Although previous studies have explored workplace violence and its consequences,^7-9,16 very little is known about nurses’ authentic and subjective experiences. Knowledge gathered from qualitative data increases understanding of experiences from individuals’ perspectives.²⁰ Qualitative evidence is needed when there is little pre-existing knowledge because it enables the complexity of a phenomenon to be analyzed from a holistic perspective.²¹ Improving knowledge about nurses’ experiences and their strategies for handling psychological strain helps us to understand the victims’ responses to violent situations. Research-based knowledge gathered from this review could be utilized when developing interventions to manage violence in the context of psychiatric nursing as well as modifying psychiatric nursing practices and updating education. The knowledge may also be applied to different health care settings.

A preliminary search of CINAHL, PROSPERO, PubMed, the Cochrane Database of Systematic Reviews, and the JBI Database of Systematic Reviews and Implementation Reports was conducted in September 2019. The search found several reviews concerning workplace violence in psychiatric nursing,^22-26 but none focused on nurses’ experiences. Hence, no previous or current systematic reviews on the topic have been identified to date, and there is a lack of qualitative evidence specifically identifying nurses’ experiences of workplace violence in the context of psychiatric nursing. This provides a strong rationale for this review. Although previous studies have indicated that workplace violence can result in numerous consequences, very little is known about nurses’ actual experiences. This review intends to address these gaps by appraising and synthesizing available evidence related to nurses’ experiences of workplace violence in the field of psychiatric nursing.

Review question

What are nurses’ experiences of workplace violence in the field of psychiatric nursing?

Inclusion criteria

Participants

The review will consider studies that include nurses (e.g., registered nurses, licensed practical nurses, nurse practitioners) who are licensed or certified psychiatric nurses or specialize in mental health after completion of specialist post-qualification education in psychiatric nursing and have experienced workplace violence. Psychiatric nursing is based on the applications of psychiatric principles and refers to nursing care of people of various ages who are experiencing mental health–related problems or diagnosed with mental illness (e.g., depression, anxiety, schizophrenia).

Phenomenon of interest

The phenomenon of interest will be experiences of workplace violence. In this review, workplace violence is defined according to the definition of the International Labour Office.³

Context

The review will consider studies that explore psychiatric nursing in mental health services in any geographic region. The types of settings will include inpatient services (e.g., long-stay hospital care, psychiatric hospitals, psychiatric units in general hospitals) and outpatient services (e.g., primary mental health care, day centers and hospitals, mental health centers, domiciliary care and home visits, residential care, mental health rehabilitation, specialist community mental health services).

Types of studies

The review will consider studies that focus on qualitative data, including, but not limited to, designs such as qualitative descriptive studies, phenomenology, grounded theory, ethnography, action research, and feminist research. Qualitative data from mixed method studies will be included if there is enough clarity to distinguish the findings from quantitative results. Studies published in English, Finnish, or Swedish will be included because they are the languages of the systematic review team. Studies in other languages will be included if there is an English translation available for the study. No publication date limits will be set for the database searches because of the paradigms of qualitative data.

Methods

The proposed review will be conducted in accordance with JBI methodology for systematic reviews of qualitative evidence.²⁰

Search strategy

The search strategy will aim to identify both published and unpublished studies. An initial limited search of CINAHL and PubMed was undertaken to identify articles on the topic. The text words contained in the titles and abstracts of relevant articles and keywords used to describe the articles were scrutinized to develop a full search strategy for CINAHL and PubMed (see Appendix I). The search strategy was developed with assistance from an information specialist from Oulu University Medical Library. The search strategy, including all identified keywords and index terms, will be adapted for each included information source. The reference lists of all studies selected for critical appraisal will be screened for additional studies.

Information sources

The databases to be searched include PubMed, CINAHL, PsycINFO, PsycARTICLES, Scopus, Web of Science, ProQuest, and Directory of Open Access Journals. Sources of unpublished studies and gray literature will be searched using ProQuest Dissertations and Theses, Google Scholar, and MedNar. The key terms that will inform the development of strategies for each database will be derived from CINAHL and will be revised and combined with free text terms before the full search is conducted in the relevant databases.

Study selection

Following the search, all identified citations will be collated and uploaded into RefWorks (ProQuest LLC, Ann Arbor, USA) and any duplicates will be removed. Titles and abstracts will then be screened by two independent reviewers for assessment against the inclusion criteria for the review. Potentially relevant studies will be retrieved in full and their citation details imported into the JBI System for the Unified Management, Assessment and Review of Information (JBI SUMARI; JBI, Adelaide, Australia). The full text of selected citations will be assessed in detail against the inclusion criteria by two independent reviewers. Reasons for the exclusion of full-text studies will be recorded and reported in the systematic review. Any disagreements between the reviewers at each stage of the study selection process will be resolved through discussion or with a third reviewer. The results of the search will be reported in full in the final systematic review and presented in a Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram.²⁷

Assessment of methodological quality

Eligible studies will be critically appraised by two independent reviewers for methodological quality using the standard JBI Critical Appraisal Checklist for Qualitative Research.²⁸ Any disagreements between the reviewers will be resolved through discussion or with a third reviewer if necessary. All studies, regardless of their methodological quality, will be subjected to data extraction and synthesis if possible. A record will be kept of all included studies detailing the title, author, location, and database of the original study. The results of the critical appraisal will be reported in narrative form and in a table.

Data extraction

Data will be extracted from studies included in the review by two independent reviewers using the standardized JBI data extraction tool.²⁰ The extracted data will include specific details about the populations, context, culture, geographical location, study methods, and phenomena of interest relevant to the review objective. Findings, and their illustrations, will be extracted and assigned a level of credibility. Any disagreements between the reviewers will be resolved through discussion or with a third reviewer. Authors of papers will be contacted to request missing or additional data if necessary.

Data synthesis

Qualitative research findings will, wherever possible, be pooled using JBI SUMARI with the meta-aggregation approach.²⁰ This will involve the aggregation or synthesis of findings to generate a set of statements that represent aggregation by assembling and categorizing findings on the basis of similarity of meaning. These categories will then be used to produce a single comprehensive set of synthesized 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.

Assessing confidence in the findings

The final synthesized findings will be graded according to the ConQual approach for establishing confidence in the output of qualitative research synthesis and presented in a Summary of Findings.²⁹ The Summary of Findings will include the major elements of the review and details on how the ConQual score was calculated. Included in the Summary of Findings will be the title, population, phenomena of interest, and context for the specific review. Each synthesized finding from the review will be presented together with the type of research informing it, scores for dependability and credibility, and overall ConQual score.

Acknowledgments

Arja Holopainen, director of the Nursing Research Foundation/Finnish Centre for Evidence-Based Health Care: A JBI Centre of Excellence, for providing feedback on the review protocol.

Sirpa Grekula, information specialist from the Oulu University Medical Library, for guiding the search strategy.