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Antecedents and precipitants of patient-related violence in the emergency department: Results from the Australian VENT Study (Violence in Emergency Nursing and Triage)
G Model AENJ-384; No. of Pages 7
ARTICLE IN PRESS Australasian Emergency Nursing Journal xxx (2017) xxx–xxx
Contents lists available at ScienceDirect
Australasian Emergency Nursing Journal journal homepage: www.elsevier.com/locate/aenj
Research paper
Antecedents and precipitants of patient-related violence in the emergency department: Results from the Australian VENT Study (Violence in Emergency Nursing and Triage) Jacqueline V. Pich a,∗ , Ashley Kable b , Mike Hazelton b,c a
Faculty of Health, University of Technology, Ultimo, NSW, Australia, Australia School of Nursing & Midwifery, University of Newcastle, Callaghan, NSW, Australia c Mental Health Nursing, School of Nursing & Midwifery, University of Newcastle, Callaghan, NSW, Australia b
a r t i c l e
i n f o
Article history: Received 8 February 2017 Received in revised form 15 May 2017 Accepted 20 May 2017 Available online xxx Keywords: Emergency departments Triage Nurses Violence Aggression Patient-related
a b s t r a c t Introduction: Workplace violence is one of the most significant and hazardous issues faced by nurses globally. It is a potentially life-threatening and life-affecting workplace hazard often downplayed as just “part of the job” for nurses. Methods: A cross-sectional design was used and data were collected using a purpose developed survey tool. Surveys were distributed to all members of the College of Emergency Nurses’ Australasia (CENA) in 2010 and 537 eligible responses were received (RR = 51%). Results: Patient-related violence was reported by 87% of nurses in the last six months. Precipitants and antecedents for episodes of violence were reported in three categories: nurse-related; patient-related and emergency-department specific factors. Triaging was identified as the highest risk nursing activity, and the triage area identified as the highest risk location in the department. Patients who presented with alcohol intoxication, substance misuse or mental health issues were identified as the groups at greatest risk for potential violence. Discussion: Patient-related violence was reported by the majority of emergency nurses surveyed. A number of precipitants and antecedents perceived to be risk factors by participants were found to be significant and are unavoidable in the working lives of emergency department nurses. © 2017 College of Emergency Nursing Australasia. Published by Elsevier Ltd. All rights reserved.
Introduction Violence in healthcare is a significant issue globally and the emergency department is one of the highest risk clinical areas for such violence. Nurses have been identified as the profession most vulnerable to patient-related violence, and emergency nurses are at greatest risk of being exposed to such violence [1]. Emergency nurses are exposed to high levels of physical and verbal violence and this has become an expected and accepted part of the job for many nurses [2,3,4]. The impact of patient-related violence is far reaching, and impacts nurses psychologically, physically and professionally. Verbal abuse can cause significant psychological trauma and stress to nurses, even if no physical injury has occurred, and this can persist for up to 12 months following an incident [5]. The types of physical
injuries sustained by nurses range from minor scratches and bruises through to serious injuries and even death. In April 2017 there were two instances where Australian emergency nurses have been held hostage by patients armed with knives [6] [7]. Exposure to patientrelated violence can have an impact on the way nurses interact with their patients, and this includes feeling less empathy and a decline in the quality of care afforded patients [8]. Patient outcomes can be compromised with a link between violence experienced by nurses and subsequent adverse events for patients identified, including the late administration of medications and an increase in the number of patient falls and medication errors [9]. The VENT Study, (Violence in Emergency Nursing and Triage), was a national study of Australian Emergency nurses’ experiences with patient-related violence. The aims of this study are to report on patient-related violence experienced by emergency nurses in Australia and to describe the precipitants and antecedents of violent episodes.
∗ Corresponding author at: Room 217, Level 7, 235 Jones St, Ultimo NSW 2007, PO Box 123, Australia. E-mail address: [email protected] (J.V. Pich). http://dx.doi.org/10.1016/j.aenj.2017.05.005 1574-6267/© 2017 College of Emergency Nursing Australasia. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Pich JV, et al. Antecedents and precipitants of patient-related violence in the emergency department: Results from the Australian VENT Study (Violence in Emergency Nursing and Triage). Australas Emerg Nurs J (2017), http://dx.doi.org/10.1016/j.aenj.2017.05.005
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2 Table 1 Study aims addressed in questionnaire. Study aim
Questions
Content of questions
References used
To measure the frequency of individual emergency nurses’ reported exposure to patient-related workplace violence and associated outcomes in the preceding six months.
9–12 20–26
[38–40]
To identify the types of violent behaviours experienced by emergency nurses. To identify emergency nurses’ perceptions of risk prevention measures and risk management strategies adopted by their employers.
12 Section 5 of the survey: 61–62 13–19 Section 6 of the survey: 63–75
To identify factors associated with patient-related workplace violence that precipitate, escalate or de-escalate episodes of violence.
Section 4: 27:60
To investigate the issue of violence with respect to young adults (16–25 years of age) and the parents of paediatric patients. To develop recommendations for employers about patient-related workplace violence and safety in the workplace for emergency nurses.
29–31
Involved in an episode of violence in the previous week and preceding six months; Estimate how many episodes; Outcomes and impact on participants. Types of verbal abuse and physical behaviours. Measured the organisational reporting of episodes and subsequent response from management; Focused of management response to and prevention of episodes of patient-related violence. Diagnoses or clinical signs and symptoms; Nursing activities; Patient specific factors and behaviours; Staffing issues; Factors specific to the ED. Age group of parents; Relationship to child. All questions were used to contribute to achieving this aim. Q74 also asked for nurses opinions about the most effective way to prevent/minimise the occurrence of patient-related violence in the ED,
All questions 74
[41–43] [40,42,44,45]
[43,44,46–55]
[56,57]
Material and methods
Sample
Study design
The inclusion criteria included nurses who had worked clinically in an Australian ED in the last six months, and were members of the College of Emergency Nurses’ Australasia (CENA).
A cross-sectional design was used and data were collected using a purpose developed survey tool. The survey included 75 questions divided into seven sections, and was developed using relevant literature (Appendix A) and expert panel advice. The definition of “violence” included verbal abuse and threats, sexual harassment as well as physical assaults. It included any episode that involved either an explicit or implicit challenge to the well-being, safety or health of ED nurses at their place of work [10].
Setting Surveys were distributed to all financial members of CENA, with an option to return the survey by mail or complete it electronically using a link to “surveymonkey”. Statistical analysis
Questionnaire Table 1 details the references that were used to develop the survey tool. The inclusion criteria were incorporated in to the first section of the survey. Section two included demographic questions and section three contained questions about participants’ experiences with patient-related violence. A six month recall period was utilised in an attempt to minimise recall bias in this study, with participants asked to estimate the number of episodes of patientrelated violence in the preceding six months. The fourth and fifth sections included questions about the factors associated with patient-related workplace violence that precipitate, escalate or de-escalate episodes of violence and the types of violent behaviour experienced. The sixth section contained questions about risk prevention measures and risk management strategies, and the final section contained an expression of interest to participate in a follow up interview. The survey tool developed by the researchers was tested on an expert panel of nurses and their suggestions incorporated into the final version to ensure face validity. The expert panel consisted of eight nurses, three of whom were working as academics and five clinically as emergency nurses. The average time taken to complete the survey was 27 min.
StataTM V11 (STATA Corp., TX, USA) was used for the analysis of the survey data. Categorical data were compared using Pearson’s chi-square analysis with 5% significance. Uni- and multivariable logistic regression analysis was performed to estimate odds ratios for these associations (both crude and adjusted). The primary outcome measure was the risk of experiencing an episode of violence in the last six months, and its association with demographic, patient-specific, nursing-specific and emergency-department specific variables. Independently associated, statistically significant variables (p < 0.05) that had less than 10% missing values were entered into a multivariate logistic regression model. These were age, years of experience working in the ED, alcohol intoxication, substance misuse and triage. The reference group was involvement in one or more episodes of patient-related violence in the last six months. Variables were reduced stepwise (p < 0.1) until only significant variables (p < 0.05) remained. Questionnaires with missing data for particular questions were omitted from analysis of that question. Ethics Approval for the project was obtained from the ethics committee at the University of Newcastle, approval number H-2010-1013.
Please cite this article in press as: Pich JV, et al. Antecedents and precipitants of patient-related violence in the emergency department: Results from the Australian VENT Study (Violence in Emergency Nursing and Triage). Australas Emerg Nurs J (2017), http://dx.doi.org/10.1016/j.aenj.2017.05.005
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J.V. Pich et al. / Australasian Emergency Nursing Journal xxx (2017) xxx–xxx Table 2 Demographic detailsa . Variable
Category
Total (n = 531) (%)
Nursing role (n = 531)
Enrolled Nurse Endorsed Enrolled Nurse Registered Nurse Clinical Nurse Consultant Clinical Nurse Specialist Clinical Nurse Educator Nurse Unit Manager Nurse Practitioner
0 5 (1) 232 (44) 22 (4) 124 (23) 52 (10) 60 (11) 36 (7) 531
Category 20–29 30–39 40–49 50–59 60+
Total (n = 526) (%) 61 (12) 147 (28) 177 (34) 123 (23) 18 (3) 526 42
Category PART TIME CASUAL
Total (n = 531) (%) 241 (45) 21 (4) 531
State or territory
Total (n = 472) (%)
New South Wales Victoria Queensland Western Australia South Australia Australian Capital Territory Tasmania Northern Territory
133 (28) 122 (26) 101 (21) 44 (9) 25 (5) 18 (4) 15 (3) 14 (3) 531
Region Metropolitan Regional Remote/other
Total (n = 472) (%) 233 (49) 218 (46) 21 (4) 472
Total Age n = (526) ∞
Total Mean Work fraction
Total GEOGRAPHICAL LOCATION (n = 472)
Total Region (n = 472)
Total a
Not all participants provided postcodes in response to these questions.
Results Questionnaires were distributed to the 1150 financial members of CENA. Of these 87 were returned as ineligible (did not meet the inclusion criteria), non-consenting or “return to sender”. The final sample size of 537/1124 corresponded to a response rate of 51%. Some respondents did not answer every question in the survey and consequently the denominator varies in the results reported throughout. In addition some participants did not indicate that they had experienced violence in the last six months, however went on to answer other questions in their survey. These responses were considered valid as the majority of the questionnaire had been completed and so were included in the results. The demographic details of the sample are provided in Table 2. The majority of nurses surveyed, 87% (455/521) had experienced violence in the last six months, and 40% (211/523) in the previous week. The number of episodes of patient-related violence reported by participants in the six months prior to completing the survey ranged from 0 to 100 with a median of eight (IQR = 16). For analysis, the number of episodes was categorised to four groups: 0–10, 11–20, 21–30, and 31–100. Participants reported experiencing between one and 100 episodes in the last six months. The majority, (285/452, 63%) reported between one and 10 episodes, however 37% (167/452) reported experiencing more than 10 episodes. Verbal abuse was the most common form of violence experienced, reported by 95% of participants (n = 427/448) with an average of 12 episodes per month per nurse.
3
The precipitants and antecedents reported by participants were grouped into three categories: nurse-related; patient-related; and emergency-department specific factors. The discussion of odds ratios in this section refers to the odds (higher or lower) of experiencing an episode of violence in the last six months. The age and years of experience of emergency nurses were found to be significant predictors of participants having experienced a violent episode in the last six months, with older nurses aged over 40 at decreased risk. The odds decreased by approximately 60% for nurses aged 40 years and older (OR = 0.41, 95% CI 0.24, 0.69), (p = 0.001). More experienced emergency nurses, were also found to have a decreased risk of violence (OR = 0.96, 95% CI 0.93, 0.99) (p = 0.006). Participants perceived the three highest risk nursing activities for patient-related violence to be triaging, communicating with patients and managing patients’ reactions to delays. Nursing activities were compared against the variable “violent episode in the last six months” using a chi-squared analysis and triaging, managing patients’ reactions to delays and restraining patients were all found to be highly significant (p < 0.001). Assisting patients in the waiting room (p = 0.001) and communicating with patients (p = 0.003) were also found to be predictors of episodes of violence, (Table 3). Triaging was determined to be the highest risk nursing activity and the results of a logistic regression analysis found that the odds of having experienced a violent episode were almost three times higher for nurses engaged in the triaging of patients (OR = 2.91, 95% CI 1.80, 4.71) (p < 0.001). Staffing issues perceived by participants to be contributing factors for patient-related violence included workload and time management issues (n = 397/506, 78%); inadequate staffing (n = 369/506, 73%); inadequate communication with patients (n = 366/506, 66%), and lack of skills to manage episodes (n = 302/506, 60%). A chi-squared analysis was conducted using episodes of violence in the last six months, and the variables “poor skills mix” (p = 0.001); “workload and time management issues” (p = 0.004) and “time/day of shift” (p = 0.026) were all found to be significant. In this context a poor skills mix refers to an increased ratio of junior or inexperienced staff on a shift, while workload and time management issues relate to the busyness of the department. A logistic regression analysis identified “poor skills mix” and “workload and time management” issues as factors predictive of a participant having experienced an episode of violence in the last six months, Table 6. Patients aged 35 years and younger were identified as the highest risk of violence by 82% of those surveyed (n = 417/507). A number of patient-specific behaviours were identified by the majority of nurses as warning signs for impending violence, including agitation (483/512, 94%), tone of voice (463/512, 90%), attitude (448/512, 88%) and pacing (446/512, 87%). A chi-squared analysis on episodes of violence and patient-specific behaviours was conducted with all behaviours found to be significant (p < 0.001). The most commonly reported clinical presentations of patients exhibiting violent behaviour were alcohol intoxication (411/491, 84%); mental health issues (380/491, 77%) and substance abuse (373/491, 76%). Further analysis was conducted with these variable using a chi-squared analysis against episodes of violence in the last six months and alcohol intoxication, mental health issues and substance misuse were all found to be highly significant (p < 0.001). In addition anxiety and agitation (p = 0.047) and delirium (p = 0.010) were found to be significant (Table 4). The results of univariate logistic regression analysis determined that alcohol intoxication, mental health issues and substance misuse were all significantly predictive of a participant having experienced an episode of violence (Table 6). Patient-specific factors perceived by participants to be risk factors for violence were similar to those reported for clinical pre-
Please cite this article in press as: Pich JV, et al. Antecedents and precipitants of patient-related violence in the emergency department: Results from the Australian VENT Study (Violence in Emergency Nursing and Triage). Australas Emerg Nurs J (2017), http://dx.doi.org/10.1016/j.aenj.2017.05.005
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Table 3 Nursing activities associated with episodes of violence in the last 6 months. Nursing activity (comparison group episode of violence in the last 6 months)
Total responses b n = 496 (%)
Chi-squared
p-value
Triaging Communicating with patients Managing patients’ reactions to delays Taking patient history Restraining patients Assisting patients in waiting room
358 (72) 329 (66) 304 (61) 217 (44) 195 (39) 150 (30)
20.21 8.84 15.19 3.04 13.59 11.91
<0.001 0.003 <0.001 0.081 <0.001 0.001
b
Participants could respond to all of these Items.
Table 4 Clinical presentation associated with episodes of violence in the last 6 months. Clinical presentation (Diagnosis or clinical signs/symptoms) (comparison group episode of violence in the last 6 months)
Total responses (n = 491) b %
Chi-squared
p-value
Alcohol intoxication Mental health issues Substance misuse Anxiety and agitation Delirium
411 (84) 380 (77) 373 (76) 217 (44) 75 (15)
25.28 25.18 15.18 3.96 6.65
<0.001 <0.001 <0.001 0.047 0.010
b
Participants could respond to all of these Items.
Table 5 Area of the department associated with episodes of violence in the last 6 months. Area of the department (comparison group episode of violence in the last 6 months)
Total responses b n = 499 (%)
Chi-squared
p-value
Triage Patient cubicles Waiting room Resuscitation room Corridors Ambulance bay
388 (78) 359 (72) 318 (64) 205 (41) 181 (36) 119 (24)
29.43 23.00 6.64 9.23 1.39 12.36
<0.001 <0.001 0.010 0.002 0.239 <0.001
b
Participants could respond to all of these Items.
sentation. The majority of nurses reported that alcohol intoxication (n = 489/512, 96%) and substance abuse (n = 477/512, 93%) were the main risk factors. Other factors included mental health diagnoses (429/512, 84%); unrealistic expectations of patients (417.512, 81%) and a past history of violence (415/512, 81%). Chi-squared analysis was conducted on these patient-specific factors and episodes of violence in the past six months and all were found to be highly significant (p < 0.001). Univariate logistic regression analysis identified alcohol intoxication, substance misuse and mental health issues as being predictive of a participant having experienced an episode of violence in the last six months (Table 6). The areas of the department participants perceived to be the highest risk areas for patient-related violence were the triage area, patient cubicles (areas for single patients) and the waiting room. A chi-squared analysis comparing area of the department to episodes of violence in the last six months found that the results for triage, patient cubicles and the ambulance bay were all highly significant (p < 0.001) (Table 5). Univariate logistic regression analysis identified the triage area, ambulance bay, patient cubicles, the waiting room and resuscitation rooms as being predictive of a participant having experienced an episode of violence in the last 6 months (Table 6). Ninety nine percent of nurses surveyed (n = 501/508) reported that long waiting times and delays were the main ED-specific precipitants for patient-related violence. Over-crowding; noise levels; lack of privacy and personal space issues also were consistently identified by nurses as factors of concern. A chi-squared analysis was performed on these factors and a violent episode in the last six months, and the “long waiting times and delays” (<0.001), and “lack of privacy” were found to be significant (p = 0.031). A univariate logistic regression analysis determined that the odds of experienc-
ing an episode of patient-related violence increased by more than five times where long waiting times and delays occurred (OR = 5.11, 95% CI 2.71-9.66), (p < 0.001). Multivariate logistic regression analysis revealed the most significant predictor for having experienced an episode of violence in last six months was working at triage (p < 0.001), with nurses working here almost three times more likely to experience an episode of violence (Table 7).
Discussion This study had a large sample size that was representative of emergency department nurses in Australia, in terms of age, years of experience and work fraction. The average age of registered nurses in 2015 was 44, with 37% aged 50 or older, and on average they worked 33.5 h per week [11]. In addition participants were drawn from all states and territories (Table 2). The majority of nurses surveyed had been exposed to an episode of violence in the last six months, with verbal abuse the most common form of violence experienced. According to The Australasian College for Emergency Medicine, upwards of 90% of emergency department staff have experienced some type of violence in their careers (ACEM, 2011). These high levels have continued to be reported in the literature since this data were collected in 2010, for example in a 2016 study of ED staff, 94% (n = 50/53) of nurses had experienced verbal abuse in the last six months and 36% (n = 19/53) had experienced physical violence [12]. These high rates are not isolated to the Australian context, but are consistently reported in studies internationally [13–17]. The age and experience of nurses were found to be significant factors for patient-related violence, with nurses under the age of 40
Please cite this article in press as: Pich JV, et al. Antecedents and precipitants of patient-related violence in the emergency department: Results from the Australian VENT Study (Violence in Emergency Nursing and Triage). Australas Emerg Nurs J (2017), http://dx.doi.org/10.1016/j.aenj.2017.05.005
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Table 6 Univariate logistic regression results. VariableEpisode of violence in the last 6 months (Reference group)
OR
95% CI
p-value
Triaging Poor skills mix Workload & time management issues Clinical presentation of alcohol intoxication Clinical presentation of mental health issues Clinical presentation of substance misuse Patient-specific factor – alcohol intoxication Patient-specific factor – substance misuse Patient-specific factor – mental health issues Triage area Ambulance bay Patient cubicle Waiting room Resuscitation rooms Long waiting times and delays
2.91 2.25 2.06 3.38 3.30 2.54 6.05 4.82 2.85 3.63 4.16 3.13 1.85 2.29 5.11
1.80–4.71 1.07–3.27 1.26–3.27 2.07–5.53 2.04–5.34 1.57–4.11 3.23–11.35 2.68–8.64 1.72–4.73 2.24–5.9 1.77–9.89 1.93–5.06 1.15–2.97 1.33–3.96 2.71–9.66
<0.001 0.027 0.004 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 0.001 <0.001 0.011 0.003 <0.001
Table 7 Multivariate logistic regression for main risk factors and episode of violence. Variable
OR
95%CI
Standard error
p-value
Episode of violence in the last 6 months (Reference group) Age Years ED Alcohol intoxication Substance misuse Triage
0.98 0.96 2.10 1.68 2.72
0.95–1.01 0.92–1.01 0.59–7.49 0.51–5.53 1.60–4.61
0.02 0.02 1.36 0.73 1.02
0.369 0.088 0.251 0.390 <0.001
found to be at higher risk of violence. This result is consistent with previous Australian and international studies that reported that younger and less experienced nursing staff were at higher risk of verbal and physical violence when compared with older and more experienced registered nurses (Edward et al., 2014) [18,19]. The results from a large European study identified those under the age of 45 years to be at greatest risk [20]. Inexperienced nurses, including nursing students, have been reported to be less able to read the cues or warning signs for potential patient-related violence, and so are more vulnerable to its occurrence [5,21]. Nurses were three times more likely to experience an episode of patient–related violence when triaging patients, and triaging continues to be identified as a high risk nursing activity in the literature [4,18,22]. As the first point of contact for patients, triage nurses are often viewed as the “gatekeepers” to the emergency department, in control of waiting times [13], and so often bear the brunt of patients’ frustrations [23]. In addition many emergency nurses lack the skills and resources to adequately manage patients who present with a mental health issue, a group identified as at risk for violence in this study, and are unable to prevent escalation of their aggressive behaviours [23,24]. A number of the highest risk nursing activities identified in this study were directly related to interactions with patients, for example communication, managing reactions to delays and assisting patients in the waiting room. It is likely that the triage nurse would be engaged in all of these activities, and so their risk of violence may be magnified. Nurses were more than twice as likely to experience patientrelated violence if a “poor skills mix” was present, where increased numbers of inexperienced or junior staff were rostered on. This was also the case with “workload and time management issues”, which relate to the large volume of patients presenting to emergency departments. A national Canadian study also identified a link between staffing and resource adequacy and the rate of patientrelated workplace violence [3]. In a result that was consistent with other studies, patients under the age of 35 were identified as the highest risk group for patientrelated violence in this study [8]. Young adults (16–25 years of age) have previously been identified as significant groups involved in
violence against triage nurses [4]. A report on the acute care hospital system in New South Wales, Australia reported that these age groups were over-represented in terms of emergency department presentations [25]. Patients who presented with alcohol intoxication and/or substance misuse were at highest risk of potential violence, increasing the risk to nurses by up to six times. People affected by alcohol and drugs were reported to be the most common source of violence in the ED in a recent Australian study [22]. Alcohol-related violence continues to be a significant issue for nurses, and is consistently referred to as a risk factor for patient-related violence in the literature, with 25% to 98% of all violent episodes being attributed in some way to alcohol misuse [13,26,27]. In a study conducted in two Australian emergency departments alcohol was the most commonly listed factor contributing to violence and aggression [28]. In a 2014 study of 2002 Australasian emergency department staff, 98% of respondents had experienced alcohol-related verbal aggression from patients and 92% physical aggression, with nurses the group most likely to have felt unsafe due to these types of behaviour [29]. Alcohol leads to impaired judgement and decreased tolerance levels in frustrating situations [15] and it has a disinhibiting effect on behaviour which may lead to exaggerated or inappropriate responses such as violence [13]. In the Australian context the consumption of alcohol is a generally accepted part of culture [30], and increasing media and public interest has focused on dangerous alcohol consumption, particularly binge drinking and associated violent behaviour in younger adults [31]. Patients with mental health issues were perceived to be a high risk group, and were found to be more than three times more likely to exhibit violence behaviours. Long waiting times are associated with overcrowding and the noise and busyness associated with this can foster an environment that is unfavourable to the management of patients with mental health issues increasing the risk of violence [23]. To reduce this risk one solution would be that patients with mental health diagnoses are prioritised and receive rapid triage and if feasible and medically appropriate, transferred to a designated mental health area with specialist staff.
Please cite this article in press as: Pich JV, et al. Antecedents and precipitants of patient-related violence in the emergency department: Results from the Australian VENT Study (Violence in Emergency Nursing and Triage). Australas Emerg Nurs J (2017), http://dx.doi.org/10.1016/j.aenj.2017.05.005
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The triage area was identified as the highest risk location in the department, increasing the likelihood of patient-related violence by more than three times. A similar result was found for the ambulance bay, which is typically located adjacent to the triage area in the department. The triage area has been consistently identified as a high risk area for violence in the literature [13,23], with estimates that more than half of all violent incidents occur at triage or within the first hour of the patient being in the emergency department [13,32]. This result has continued to be reported in the literature, and one recent study described it as the primary area for violent and aggressive acts towards ED staff [33]. Workplace design has been identified as a major factor that could potentially promote the safety of nurses or increase their risk of being victimised [34]. This is particularly the case for the triage area with poor layout and inadequate size identified as key risk factors for patient-related violence in a number of recent studies [33] [35]. Long waiting times and delays were found to be significantly associated with violence, increasing the risk by more than five times. Long waiting times continue to be reported as a risk factor for violence. For example in a 2014 Australian study of emergency nurses, long waiting time were perceived to be one the highest causative factors for violence and aggression by patients [22]. A 2014 Irish study had similar findings and reported a link between episodes of aggression and patients who had been waiting in the department for a number of hours [33]. Dissatisfaction with waiting times has been reported as a crucial trigger for violence in a number of earlier other studies [13,23,32], and it is worth noting that waiting times can continue after patients have been admitted to the department, for example delays for test results, specialist consultations or prior to being transferred to a ward [36].
Conclusions The findings from the VENT Study, a national Australian study, have confirmed that emergency department nurses are working in a high-risk environment. In the six years since the data in this survey were collected patient-related violence against emergency department nurses remains a significant workplace hazard, with two violent attacks reported in the media recently. The risk factors for patient-related violence identified were multi-factorial and include nurse-related, patient-related and factors specific to the emergency department itself. These factors can combine or overlap to create a situation where violence may be inevitable, however by developing an awareness of these risks nurses are better placed to manage such situations and mitigate these risk factors. Funding Nil obtained. Authorship: statement about contributorship JP conceived and designed the study with assistance from AK and MH. JP developed the study protocol with assistance from AK and MH. JP developed the study protocol with assistance from AK and MH. JP designed the study instruments with assistance from AK and JP and AK tested the study instruments. JP supervised data collection. JP, AK and MH analysed the data. JP, AK and MH prepared and approved the manuscript.
Limitations The age of the data reported here is acknowledged as a limitation, however the study is still relevant as the issue of patientrelated violence continues to be reported as a major issue for emergency nurses. While the sample size, representativeness and response rate for the study were better than in previous studies [37], these results may not be generalisable within Australia and overseas as the data were collected from a sample of CENA nurses only. The results may have been affected by non-response and selfselection bias and the retrospective nature of the research, using a six month recall period, may have resulted in recall bias and underreporting. Data were collected using a self-reported survey tool and so the results presented are based on the perceptions of this sample of emergency nurses. Finally the reliability of the survey tool was not validated.
Implications for emergency nurses Patient-related violence was reported by the majority of emergency nurses surveyed, and is an issue that continues to be a major workplace concern. A number of precipitants and antecedents were found to be significant and are unavoidable in the working lives of emergency department nurses. Triage nurses were identified as being at highest risk of such violence, and many of the precipitants identified as significant are directly related to their role including triaging, long waiting times and delays and patients presenting with alcohol intoxication, substance misuse and/or mental health issues. These factors were all predictive of a participant having experienced an episode of violence in the last six months and were found to increase this risk of violence by up to five-times.
Conflict of interest None. Acknowledgements The authors would like to thank the College of Emergency Nursing Australasia for their support of this study and the nurses who participated. We would also like to thank Dr Christopher Oldmeadow for his assistance with the statistical analysis of data. Appendix A. Supplementary data Supplementary data associated with this article can be found, in the online version, at http://dx.doi.org/10.1016/j.aenj.2017.05.005. References [1] Camerino D, Estryn-Behar M, Conway PM, van Der Heijden BI, Hasselhorn HM. Work-related factors and violence among nursing staff in the European NEXT study: a longitudinal cohort study. Int J Nurs Stud 2008;45(1):35–50. [2] Pich J, Kable A. Patient-related violence against nursing staff working in emergency departments: a systematic review. JBI Database System Rev Implement Rep 2014;12(9):398–453. [3] Shields M, Wilkins K. Factors related to on-the-job abuse of nurses by patients. Health Rep 2009;20(2):7–19. [4] Pich J, Hazelton M, Sundin D, Kable A. Patient-related violence at triage: a qualitative descriptive study. Int Emerg Nurs 2011;19(1):12–9. [5] Gerberich SG, Church TR, McGovern PM, Hansen HE, Nachreiner NM, Geisser MS, et al. An epidemiological study of the magnitude and consequences of work related violence: the Minnesota Nurses’ Study. Occup Environ Med 2004;61(6):495–503. [6] Bowden E. Nurse taken hostage by knife-wielding patient at Royal Melbourne Hospital. In: The Age; 2017.
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Contents lists available at ScienceDirect
Australasian Emergency Nursing Journal journal homepage: www.elsevier.com/locate/aenj
Research paper
Antecedents and precipitants of patient-related violence in the emergency department: Results from the Australian VENT Study (Violence in Emergency Nursing and Triage) Jacqueline V. Pich a,∗ , Ashley Kable b , Mike Hazelton b,c a
Faculty of Health, University of Technology, Ultimo, NSW, Australia, Australia School of Nursing & Midwifery, University of Newcastle, Callaghan, NSW, Australia c Mental Health Nursing, School of Nursing & Midwifery, University of Newcastle, Callaghan, NSW, Australia b
a r t i c l e
i n f o
Article history: Received 8 February 2017 Received in revised form 15 May 2017 Accepted 20 May 2017 Available online xxx Keywords: Emergency departments Triage Nurses Violence Aggression Patient-related
a b s t r a c t Introduction: Workplace violence is one of the most significant and hazardous issues faced by nurses globally. It is a potentially life-threatening and life-affecting workplace hazard often downplayed as just “part of the job” for nurses. Methods: A cross-sectional design was used and data were collected using a purpose developed survey tool. Surveys were distributed to all members of the College of Emergency Nurses’ Australasia (CENA) in 2010 and 537 eligible responses were received (RR = 51%). Results: Patient-related violence was reported by 87% of nurses in the last six months. Precipitants and antecedents for episodes of violence were reported in three categories: nurse-related; patient-related and emergency-department specific factors. Triaging was identified as the highest risk nursing activity, and the triage area identified as the highest risk location in the department. Patients who presented with alcohol intoxication, substance misuse or mental health issues were identified as the groups at greatest risk for potential violence. Discussion: Patient-related violence was reported by the majority of emergency nurses surveyed. A number of precipitants and antecedents perceived to be risk factors by participants were found to be significant and are unavoidable in the working lives of emergency department nurses. © 2017 College of Emergency Nursing Australasia. Published by Elsevier Ltd. All rights reserved.
Introduction Violence in healthcare is a significant issue globally and the emergency department is one of the highest risk clinical areas for such violence. Nurses have been identified as the profession most vulnerable to patient-related violence, and emergency nurses are at greatest risk of being exposed to such violence [1]. Emergency nurses are exposed to high levels of physical and verbal violence and this has become an expected and accepted part of the job for many nurses [2,3,4]. The impact of patient-related violence is far reaching, and impacts nurses psychologically, physically and professionally. Verbal abuse can cause significant psychological trauma and stress to nurses, even if no physical injury has occurred, and this can persist for up to 12 months following an incident [5]. The types of physical
injuries sustained by nurses range from minor scratches and bruises through to serious injuries and even death. In April 2017 there were two instances where Australian emergency nurses have been held hostage by patients armed with knives [6] [7]. Exposure to patientrelated violence can have an impact on the way nurses interact with their patients, and this includes feeling less empathy and a decline in the quality of care afforded patients [8]. Patient outcomes can be compromised with a link between violence experienced by nurses and subsequent adverse events for patients identified, including the late administration of medications and an increase in the number of patient falls and medication errors [9]. The VENT Study, (Violence in Emergency Nursing and Triage), was a national study of Australian Emergency nurses’ experiences with patient-related violence. The aims of this study are to report on patient-related violence experienced by emergency nurses in Australia and to describe the precipitants and antecedents of violent episodes.
∗ Corresponding author at: Room 217, Level 7, 235 Jones St, Ultimo NSW 2007, PO Box 123, Australia. E-mail address: [email protected] (J.V. Pich). http://dx.doi.org/10.1016/j.aenj.2017.05.005 1574-6267/© 2017 College of Emergency Nursing Australasia. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Pich JV, et al. Antecedents and precipitants of patient-related violence in the emergency department: Results from the Australian VENT Study (Violence in Emergency Nursing and Triage). Australas Emerg Nurs J (2017), http://dx.doi.org/10.1016/j.aenj.2017.05.005
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2 Table 1 Study aims addressed in questionnaire. Study aim
Questions
Content of questions
References used
To measure the frequency of individual emergency nurses’ reported exposure to patient-related workplace violence and associated outcomes in the preceding six months.
9–12 20–26
[38–40]
To identify the types of violent behaviours experienced by emergency nurses. To identify emergency nurses’ perceptions of risk prevention measures and risk management strategies adopted by their employers.
12 Section 5 of the survey: 61–62 13–19 Section 6 of the survey: 63–75
To identify factors associated with patient-related workplace violence that precipitate, escalate or de-escalate episodes of violence.
Section 4: 27:60
To investigate the issue of violence with respect to young adults (16–25 years of age) and the parents of paediatric patients. To develop recommendations for employers about patient-related workplace violence and safety in the workplace for emergency nurses.
29–31
Involved in an episode of violence in the previous week and preceding six months; Estimate how many episodes; Outcomes and impact on participants. Types of verbal abuse and physical behaviours. Measured the organisational reporting of episodes and subsequent response from management; Focused of management response to and prevention of episodes of patient-related violence. Diagnoses or clinical signs and symptoms; Nursing activities; Patient specific factors and behaviours; Staffing issues; Factors specific to the ED. Age group of parents; Relationship to child. All questions were used to contribute to achieving this aim. Q74 also asked for nurses opinions about the most effective way to prevent/minimise the occurrence of patient-related violence in the ED,
All questions 74
[41–43] [40,42,44,45]
[43,44,46–55]
[56,57]
Material and methods
Sample
Study design
The inclusion criteria included nurses who had worked clinically in an Australian ED in the last six months, and were members of the College of Emergency Nurses’ Australasia (CENA).
A cross-sectional design was used and data were collected using a purpose developed survey tool. The survey included 75 questions divided into seven sections, and was developed using relevant literature (Appendix A) and expert panel advice. The definition of “violence” included verbal abuse and threats, sexual harassment as well as physical assaults. It included any episode that involved either an explicit or implicit challenge to the well-being, safety or health of ED nurses at their place of work [10].
Setting Surveys were distributed to all financial members of CENA, with an option to return the survey by mail or complete it electronically using a link to “surveymonkey”. Statistical analysis
Questionnaire Table 1 details the references that were used to develop the survey tool. The inclusion criteria were incorporated in to the first section of the survey. Section two included demographic questions and section three contained questions about participants’ experiences with patient-related violence. A six month recall period was utilised in an attempt to minimise recall bias in this study, with participants asked to estimate the number of episodes of patientrelated violence in the preceding six months. The fourth and fifth sections included questions about the factors associated with patient-related workplace violence that precipitate, escalate or de-escalate episodes of violence and the types of violent behaviour experienced. The sixth section contained questions about risk prevention measures and risk management strategies, and the final section contained an expression of interest to participate in a follow up interview. The survey tool developed by the researchers was tested on an expert panel of nurses and their suggestions incorporated into the final version to ensure face validity. The expert panel consisted of eight nurses, three of whom were working as academics and five clinically as emergency nurses. The average time taken to complete the survey was 27 min.
StataTM V11 (STATA Corp., TX, USA) was used for the analysis of the survey data. Categorical data were compared using Pearson’s chi-square analysis with 5% significance. Uni- and multivariable logistic regression analysis was performed to estimate odds ratios for these associations (both crude and adjusted). The primary outcome measure was the risk of experiencing an episode of violence in the last six months, and its association with demographic, patient-specific, nursing-specific and emergency-department specific variables. Independently associated, statistically significant variables (p < 0.05) that had less than 10% missing values were entered into a multivariate logistic regression model. These were age, years of experience working in the ED, alcohol intoxication, substance misuse and triage. The reference group was involvement in one or more episodes of patient-related violence in the last six months. Variables were reduced stepwise (p < 0.1) until only significant variables (p < 0.05) remained. Questionnaires with missing data for particular questions were omitted from analysis of that question. Ethics Approval for the project was obtained from the ethics committee at the University of Newcastle, approval number H-2010-1013.
Please cite this article in press as: Pich JV, et al. Antecedents and precipitants of patient-related violence in the emergency department: Results from the Australian VENT Study (Violence in Emergency Nursing and Triage). Australas Emerg Nurs J (2017), http://dx.doi.org/10.1016/j.aenj.2017.05.005
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J.V. Pich et al. / Australasian Emergency Nursing Journal xxx (2017) xxx–xxx Table 2 Demographic detailsa . Variable
Category
Total (n = 531) (%)
Nursing role (n = 531)
Enrolled Nurse Endorsed Enrolled Nurse Registered Nurse Clinical Nurse Consultant Clinical Nurse Specialist Clinical Nurse Educator Nurse Unit Manager Nurse Practitioner
0 5 (1) 232 (44) 22 (4) 124 (23) 52 (10) 60 (11) 36 (7) 531
Category 20–29 30–39 40–49 50–59 60+
Total (n = 526) (%) 61 (12) 147 (28) 177 (34) 123 (23) 18 (3) 526 42
Category PART TIME CASUAL
Total (n = 531) (%) 241 (45) 21 (4) 531
State or territory
Total (n = 472) (%)
New South Wales Victoria Queensland Western Australia South Australia Australian Capital Territory Tasmania Northern Territory
133 (28) 122 (26) 101 (21) 44 (9) 25 (5) 18 (4) 15 (3) 14 (3) 531
Region Metropolitan Regional Remote/other
Total (n = 472) (%) 233 (49) 218 (46) 21 (4) 472
Total Age n = (526) ∞
Total Mean Work fraction
Total GEOGRAPHICAL LOCATION (n = 472)
Total Region (n = 472)
Total a
Not all participants provided postcodes in response to these questions.
Results Questionnaires were distributed to the 1150 financial members of CENA. Of these 87 were returned as ineligible (did not meet the inclusion criteria), non-consenting or “return to sender”. The final sample size of 537/1124 corresponded to a response rate of 51%. Some respondents did not answer every question in the survey and consequently the denominator varies in the results reported throughout. In addition some participants did not indicate that they had experienced violence in the last six months, however went on to answer other questions in their survey. These responses were considered valid as the majority of the questionnaire had been completed and so were included in the results. The demographic details of the sample are provided in Table 2. The majority of nurses surveyed, 87% (455/521) had experienced violence in the last six months, and 40% (211/523) in the previous week. The number of episodes of patient-related violence reported by participants in the six months prior to completing the survey ranged from 0 to 100 with a median of eight (IQR = 16). For analysis, the number of episodes was categorised to four groups: 0–10, 11–20, 21–30, and 31–100. Participants reported experiencing between one and 100 episodes in the last six months. The majority, (285/452, 63%) reported between one and 10 episodes, however 37% (167/452) reported experiencing more than 10 episodes. Verbal abuse was the most common form of violence experienced, reported by 95% of participants (n = 427/448) with an average of 12 episodes per month per nurse.
3
The precipitants and antecedents reported by participants were grouped into three categories: nurse-related; patient-related; and emergency-department specific factors. The discussion of odds ratios in this section refers to the odds (higher or lower) of experiencing an episode of violence in the last six months. The age and years of experience of emergency nurses were found to be significant predictors of participants having experienced a violent episode in the last six months, with older nurses aged over 40 at decreased risk. The odds decreased by approximately 60% for nurses aged 40 years and older (OR = 0.41, 95% CI 0.24, 0.69), (p = 0.001). More experienced emergency nurses, were also found to have a decreased risk of violence (OR = 0.96, 95% CI 0.93, 0.99) (p = 0.006). Participants perceived the three highest risk nursing activities for patient-related violence to be triaging, communicating with patients and managing patients’ reactions to delays. Nursing activities were compared against the variable “violent episode in the last six months” using a chi-squared analysis and triaging, managing patients’ reactions to delays and restraining patients were all found to be highly significant (p < 0.001). Assisting patients in the waiting room (p = 0.001) and communicating with patients (p = 0.003) were also found to be predictors of episodes of violence, (Table 3). Triaging was determined to be the highest risk nursing activity and the results of a logistic regression analysis found that the odds of having experienced a violent episode were almost three times higher for nurses engaged in the triaging of patients (OR = 2.91, 95% CI 1.80, 4.71) (p < 0.001). Staffing issues perceived by participants to be contributing factors for patient-related violence included workload and time management issues (n = 397/506, 78%); inadequate staffing (n = 369/506, 73%); inadequate communication with patients (n = 366/506, 66%), and lack of skills to manage episodes (n = 302/506, 60%). A chi-squared analysis was conducted using episodes of violence in the last six months, and the variables “poor skills mix” (p = 0.001); “workload and time management issues” (p = 0.004) and “time/day of shift” (p = 0.026) were all found to be significant. In this context a poor skills mix refers to an increased ratio of junior or inexperienced staff on a shift, while workload and time management issues relate to the busyness of the department. A logistic regression analysis identified “poor skills mix” and “workload and time management” issues as factors predictive of a participant having experienced an episode of violence in the last six months, Table 6. Patients aged 35 years and younger were identified as the highest risk of violence by 82% of those surveyed (n = 417/507). A number of patient-specific behaviours were identified by the majority of nurses as warning signs for impending violence, including agitation (483/512, 94%), tone of voice (463/512, 90%), attitude (448/512, 88%) and pacing (446/512, 87%). A chi-squared analysis on episodes of violence and patient-specific behaviours was conducted with all behaviours found to be significant (p < 0.001). The most commonly reported clinical presentations of patients exhibiting violent behaviour were alcohol intoxication (411/491, 84%); mental health issues (380/491, 77%) and substance abuse (373/491, 76%). Further analysis was conducted with these variable using a chi-squared analysis against episodes of violence in the last six months and alcohol intoxication, mental health issues and substance misuse were all found to be highly significant (p < 0.001). In addition anxiety and agitation (p = 0.047) and delirium (p = 0.010) were found to be significant (Table 4). The results of univariate logistic regression analysis determined that alcohol intoxication, mental health issues and substance misuse were all significantly predictive of a participant having experienced an episode of violence (Table 6). Patient-specific factors perceived by participants to be risk factors for violence were similar to those reported for clinical pre-
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Table 3 Nursing activities associated with episodes of violence in the last 6 months. Nursing activity (comparison group episode of violence in the last 6 months)
Total responses b n = 496 (%)
Chi-squared
p-value
Triaging Communicating with patients Managing patients’ reactions to delays Taking patient history Restraining patients Assisting patients in waiting room
358 (72) 329 (66) 304 (61) 217 (44) 195 (39) 150 (30)
20.21 8.84 15.19 3.04 13.59 11.91
<0.001 0.003 <0.001 0.081 <0.001 0.001
b
Participants could respond to all of these Items.
Table 4 Clinical presentation associated with episodes of violence in the last 6 months. Clinical presentation (Diagnosis or clinical signs/symptoms) (comparison group episode of violence in the last 6 months)
Total responses (n = 491) b %
Chi-squared
p-value
Alcohol intoxication Mental health issues Substance misuse Anxiety and agitation Delirium
411 (84) 380 (77) 373 (76) 217 (44) 75 (15)
25.28 25.18 15.18 3.96 6.65
<0.001 <0.001 <0.001 0.047 0.010
b
Participants could respond to all of these Items.
Table 5 Area of the department associated with episodes of violence in the last 6 months. Area of the department (comparison group episode of violence in the last 6 months)
Total responses b n = 499 (%)
Chi-squared
p-value
Triage Patient cubicles Waiting room Resuscitation room Corridors Ambulance bay
388 (78) 359 (72) 318 (64) 205 (41) 181 (36) 119 (24)
29.43 23.00 6.64 9.23 1.39 12.36
<0.001 <0.001 0.010 0.002 0.239 <0.001
b
Participants could respond to all of these Items.
sentation. The majority of nurses reported that alcohol intoxication (n = 489/512, 96%) and substance abuse (n = 477/512, 93%) were the main risk factors. Other factors included mental health diagnoses (429/512, 84%); unrealistic expectations of patients (417.512, 81%) and a past history of violence (415/512, 81%). Chi-squared analysis was conducted on these patient-specific factors and episodes of violence in the past six months and all were found to be highly significant (p < 0.001). Univariate logistic regression analysis identified alcohol intoxication, substance misuse and mental health issues as being predictive of a participant having experienced an episode of violence in the last six months (Table 6). The areas of the department participants perceived to be the highest risk areas for patient-related violence were the triage area, patient cubicles (areas for single patients) and the waiting room. A chi-squared analysis comparing area of the department to episodes of violence in the last six months found that the results for triage, patient cubicles and the ambulance bay were all highly significant (p < 0.001) (Table 5). Univariate logistic regression analysis identified the triage area, ambulance bay, patient cubicles, the waiting room and resuscitation rooms as being predictive of a participant having experienced an episode of violence in the last 6 months (Table 6). Ninety nine percent of nurses surveyed (n = 501/508) reported that long waiting times and delays were the main ED-specific precipitants for patient-related violence. Over-crowding; noise levels; lack of privacy and personal space issues also were consistently identified by nurses as factors of concern. A chi-squared analysis was performed on these factors and a violent episode in the last six months, and the “long waiting times and delays” (<0.001), and “lack of privacy” were found to be significant (p = 0.031). A univariate logistic regression analysis determined that the odds of experienc-
ing an episode of patient-related violence increased by more than five times where long waiting times and delays occurred (OR = 5.11, 95% CI 2.71-9.66), (p < 0.001). Multivariate logistic regression analysis revealed the most significant predictor for having experienced an episode of violence in last six months was working at triage (p < 0.001), with nurses working here almost three times more likely to experience an episode of violence (Table 7).
Discussion This study had a large sample size that was representative of emergency department nurses in Australia, in terms of age, years of experience and work fraction. The average age of registered nurses in 2015 was 44, with 37% aged 50 or older, and on average they worked 33.5 h per week [11]. In addition participants were drawn from all states and territories (Table 2). The majority of nurses surveyed had been exposed to an episode of violence in the last six months, with verbal abuse the most common form of violence experienced. According to The Australasian College for Emergency Medicine, upwards of 90% of emergency department staff have experienced some type of violence in their careers (ACEM, 2011). These high levels have continued to be reported in the literature since this data were collected in 2010, for example in a 2016 study of ED staff, 94% (n = 50/53) of nurses had experienced verbal abuse in the last six months and 36% (n = 19/53) had experienced physical violence [12]. These high rates are not isolated to the Australian context, but are consistently reported in studies internationally [13–17]. The age and experience of nurses were found to be significant factors for patient-related violence, with nurses under the age of 40
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Table 6 Univariate logistic regression results. VariableEpisode of violence in the last 6 months (Reference group)
OR
95% CI
p-value
Triaging Poor skills mix Workload & time management issues Clinical presentation of alcohol intoxication Clinical presentation of mental health issues Clinical presentation of substance misuse Patient-specific factor – alcohol intoxication Patient-specific factor – substance misuse Patient-specific factor – mental health issues Triage area Ambulance bay Patient cubicle Waiting room Resuscitation rooms Long waiting times and delays
2.91 2.25 2.06 3.38 3.30 2.54 6.05 4.82 2.85 3.63 4.16 3.13 1.85 2.29 5.11
1.80–4.71 1.07–3.27 1.26–3.27 2.07–5.53 2.04–5.34 1.57–4.11 3.23–11.35 2.68–8.64 1.72–4.73 2.24–5.9 1.77–9.89 1.93–5.06 1.15–2.97 1.33–3.96 2.71–9.66
<0.001 0.027 0.004 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 0.001 <0.001 0.011 0.003 <0.001
Table 7 Multivariate logistic regression for main risk factors and episode of violence. Variable
OR
95%CI
Standard error
p-value
Episode of violence in the last 6 months (Reference group) Age Years ED Alcohol intoxication Substance misuse Triage
0.98 0.96 2.10 1.68 2.72
0.95–1.01 0.92–1.01 0.59–7.49 0.51–5.53 1.60–4.61
0.02 0.02 1.36 0.73 1.02
0.369 0.088 0.251 0.390 <0.001
found to be at higher risk of violence. This result is consistent with previous Australian and international studies that reported that younger and less experienced nursing staff were at higher risk of verbal and physical violence when compared with older and more experienced registered nurses (Edward et al., 2014) [18,19]. The results from a large European study identified those under the age of 45 years to be at greatest risk [20]. Inexperienced nurses, including nursing students, have been reported to be less able to read the cues or warning signs for potential patient-related violence, and so are more vulnerable to its occurrence [5,21]. Nurses were three times more likely to experience an episode of patient–related violence when triaging patients, and triaging continues to be identified as a high risk nursing activity in the literature [4,18,22]. As the first point of contact for patients, triage nurses are often viewed as the “gatekeepers” to the emergency department, in control of waiting times [13], and so often bear the brunt of patients’ frustrations [23]. In addition many emergency nurses lack the skills and resources to adequately manage patients who present with a mental health issue, a group identified as at risk for violence in this study, and are unable to prevent escalation of their aggressive behaviours [23,24]. A number of the highest risk nursing activities identified in this study were directly related to interactions with patients, for example communication, managing reactions to delays and assisting patients in the waiting room. It is likely that the triage nurse would be engaged in all of these activities, and so their risk of violence may be magnified. Nurses were more than twice as likely to experience patientrelated violence if a “poor skills mix” was present, where increased numbers of inexperienced or junior staff were rostered on. This was also the case with “workload and time management issues”, which relate to the large volume of patients presenting to emergency departments. A national Canadian study also identified a link between staffing and resource adequacy and the rate of patientrelated workplace violence [3]. In a result that was consistent with other studies, patients under the age of 35 were identified as the highest risk group for patientrelated violence in this study [8]. Young adults (16–25 years of age) have previously been identified as significant groups involved in
violence against triage nurses [4]. A report on the acute care hospital system in New South Wales, Australia reported that these age groups were over-represented in terms of emergency department presentations [25]. Patients who presented with alcohol intoxication and/or substance misuse were at highest risk of potential violence, increasing the risk to nurses by up to six times. People affected by alcohol and drugs were reported to be the most common source of violence in the ED in a recent Australian study [22]. Alcohol-related violence continues to be a significant issue for nurses, and is consistently referred to as a risk factor for patient-related violence in the literature, with 25% to 98% of all violent episodes being attributed in some way to alcohol misuse [13,26,27]. In a study conducted in two Australian emergency departments alcohol was the most commonly listed factor contributing to violence and aggression [28]. In a 2014 study of 2002 Australasian emergency department staff, 98% of respondents had experienced alcohol-related verbal aggression from patients and 92% physical aggression, with nurses the group most likely to have felt unsafe due to these types of behaviour [29]. Alcohol leads to impaired judgement and decreased tolerance levels in frustrating situations [15] and it has a disinhibiting effect on behaviour which may lead to exaggerated or inappropriate responses such as violence [13]. In the Australian context the consumption of alcohol is a generally accepted part of culture [30], and increasing media and public interest has focused on dangerous alcohol consumption, particularly binge drinking and associated violent behaviour in younger adults [31]. Patients with mental health issues were perceived to be a high risk group, and were found to be more than three times more likely to exhibit violence behaviours. Long waiting times are associated with overcrowding and the noise and busyness associated with this can foster an environment that is unfavourable to the management of patients with mental health issues increasing the risk of violence [23]. To reduce this risk one solution would be that patients with mental health diagnoses are prioritised and receive rapid triage and if feasible and medically appropriate, transferred to a designated mental health area with specialist staff.
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The triage area was identified as the highest risk location in the department, increasing the likelihood of patient-related violence by more than three times. A similar result was found for the ambulance bay, which is typically located adjacent to the triage area in the department. The triage area has been consistently identified as a high risk area for violence in the literature [13,23], with estimates that more than half of all violent incidents occur at triage or within the first hour of the patient being in the emergency department [13,32]. This result has continued to be reported in the literature, and one recent study described it as the primary area for violent and aggressive acts towards ED staff [33]. Workplace design has been identified as a major factor that could potentially promote the safety of nurses or increase their risk of being victimised [34]. This is particularly the case for the triage area with poor layout and inadequate size identified as key risk factors for patient-related violence in a number of recent studies [33] [35]. Long waiting times and delays were found to be significantly associated with violence, increasing the risk by more than five times. Long waiting times continue to be reported as a risk factor for violence. For example in a 2014 Australian study of emergency nurses, long waiting time were perceived to be one the highest causative factors for violence and aggression by patients [22]. A 2014 Irish study had similar findings and reported a link between episodes of aggression and patients who had been waiting in the department for a number of hours [33]. Dissatisfaction with waiting times has been reported as a crucial trigger for violence in a number of earlier other studies [13,23,32], and it is worth noting that waiting times can continue after patients have been admitted to the department, for example delays for test results, specialist consultations or prior to being transferred to a ward [36].
Conclusions The findings from the VENT Study, a national Australian study, have confirmed that emergency department nurses are working in a high-risk environment. In the six years since the data in this survey were collected patient-related violence against emergency department nurses remains a significant workplace hazard, with two violent attacks reported in the media recently. The risk factors for patient-related violence identified were multi-factorial and include nurse-related, patient-related and factors specific to the emergency department itself. These factors can combine or overlap to create a situation where violence may be inevitable, however by developing an awareness of these risks nurses are better placed to manage such situations and mitigate these risk factors. Funding Nil obtained. Authorship: statement about contributorship JP conceived and designed the study with assistance from AK and MH. JP developed the study protocol with assistance from AK and MH. JP developed the study protocol with assistance from AK and MH. JP designed the study instruments with assistance from AK and JP and AK tested the study instruments. JP supervised data collection. JP, AK and MH analysed the data. JP, AK and MH prepared and approved the manuscript.
Limitations The age of the data reported here is acknowledged as a limitation, however the study is still relevant as the issue of patientrelated violence continues to be reported as a major issue for emergency nurses. While the sample size, representativeness and response rate for the study were better than in previous studies [37], these results may not be generalisable within Australia and overseas as the data were collected from a sample of CENA nurses only. The results may have been affected by non-response and selfselection bias and the retrospective nature of the research, using a six month recall period, may have resulted in recall bias and underreporting. Data were collected using a self-reported survey tool and so the results presented are based on the perceptions of this sample of emergency nurses. Finally the reliability of the survey tool was not validated.
Implications for emergency nurses Patient-related violence was reported by the majority of emergency nurses surveyed, and is an issue that continues to be a major workplace concern. A number of precipitants and antecedents were found to be significant and are unavoidable in the working lives of emergency department nurses. Triage nurses were identified as being at highest risk of such violence, and many of the precipitants identified as significant are directly related to their role including triaging, long waiting times and delays and patients presenting with alcohol intoxication, substance misuse and/or mental health issues. These factors were all predictive of a participant having experienced an episode of violence in the last six months and were found to increase this risk of violence by up to five-times.
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Please cite this article in press as: Pich JV, et al. Antecedents and precipitants of patient-related violence in the emergency department: Results from the Australian VENT Study (Violence in Emergency Nursing and Triage). Australas Emerg Nurs J (2017), http://dx.doi.org/10.1016/j.aenj.2017.05.005