- Email: [email protected]
Occupational Disappointment: Why Did I Even Become a Nurse?
RESEARCH
OCCUPATIONAL DISAPPOINTMENT: WHY DID I EVEN BECOME A NURSE? Authors: Rebekah J. Howerton Child, PhD, RN, and Elizabeth J. Sussman, PhD, RD, Northridge, CA
Contribution to Emergency Practice:
• This research is new, as—to the researchers’ knowledge— very little research using grounded-theory methodology has been done about verbal workplace violence (VWPV) in emergency departments in the United States. • Although the emergency nursing society is well aware of the problem of workplace violence, this study illuminates some new and interesting themes that will contribute information to the practice of emergency nursing. These themes include occupational disappointment and specific personality types that can prevent or de-escalate workplace violence. • Translation of this article’s findings to emergency nursing practice includes discussing occupational disappointment with both new and seasoned nurses. Protective and causative factors should be identified internally and addressed as needed. • Identifying specific personality types among staff members might be useful in protecting nurses from the deleterious effects of VWPV. • Emergency departments need consistently to evaluate and re-evaluate mandatory violence prevention courses that are provided by hospitals and that ensure nurses are being provided “real time” tools for proper management of VWPV.
orkplace violence of all types in the emergency department is a current focus of literature and development of policies and procedures. Numerous regulatory and professional agencies have placed workplace violence (WPV) on research agendas and group
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Rebekah J. Howerton Child, is Assistant Professor, Department of Nursing, California State University, Northridge, CA. Elizabeth J. Sussman, is Assistant Professor and Graduate Coordinator, Department of Family and Consumer Sciences, California State University, Northridge, CA. For correspondence, write: Rebekah J. Howerton Child, PhD, RN, 18111 Nordhoff Street, Northridge, CA 91330-8303; E-mail: [email protected]. J Emerg Nurs ■. 0099-1767 Copyright © 2017 Emergency Nurses Association. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jen.2017.06.004
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Abstract Introduction: The aim of this study was to identify patterns of
feelings and behavior of ED RNs who have experienced verbal workplace violence. Methods: Twenty-eight registered nurses from across the
state of California were recruited. Data were collected, using in-depth interviews, and were recorded. The tapes were transcribed and analyzed using Glaserian grounded-theory methodology. Results: The main experiences of participants included occupational disappointment, peer support, lack of preparation by mandatory violence prevention classes, and unrealistic patient expectations. Discussion: These findings can help staff, managers, and
future educators of ED RNs examine feelings, mitigate the profound and pervasive effects of VWPV, and improve patient care. Key Words: Workplace violence; Emergency nursing; Grounded
theory; Occupational disappointment
statements, including The Joint Commission (TJC), the American College of Emergency Physicians, the American Nurses Association, the Emergency Nurses Association (ENA), The Occupational Safety and Health Administration, and the National Institute for Occupational Safety and Health. The Occupational Safety and Health Administration defines WPV as "any act or threat of physical violence, harassment, intimidation, or other threatening disruptive behavior that occurs at the work site. It ranges from threats and verbal abuse to physical assaults and even homicide." 1
Background
Those working in the health care profession are expected to help people; therefore, it is counterintuitive that health care workers are more likely to be attacked than police officers or
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prison guards 2 and that health care workers account for 48% of all nonfatal injuries from workplace assaults. 1 The estimated incidence of physical WPV (PWPV) ranged from 42% to 72% in a 6- to 12-month period in various studies. 3 Other studies have reported a staggering statistic that 99% of ED RNs have experienced verbal WPV (VWPV) within a 3-month period. 3–7 These estimates are generally considered to be on the low side, as the majority of WPV remains grossly underreported. 3 The effects of WPV are far reaching and produce a heavy financial and emotional burden. Days off work, workers’ compensation claims, staff turnover, and other various medical and legal expenses are estimated to cost billions annually. 7–9 The emotional burden of violence of both types (physical and verbal) can lead to negative effects for both the ED RN and, subsequently, the patient care they render. 10–12 Decreased or negative coping skills may lead to substance abuse, increased absenteeism, stress, anxiety, and intent to leave. 13 The emergency department is at highest risk for WPV of any type, owing to its ease of access by the public, 24-hour availability, perceived chaos, acute nature of patients’ physical complaints, and high levels of stress by those who visit emergency departments for their health care needs. Also, the degree to which emergency departments see acutely intoxicated and psychotic patients also increases the levels and types of WPV. 3,14–16 The efficacy of policies, procedures, and programs to mitigate all types of WPV prevention programs has not been well-established. Implementing a "Zero Tolerance" policy has been recommended by the ENA and TJC, but whether or not these policies are effective in reducing violence is unknown at this time. 3,17 Mandatory classes that ED staff may take to provide tools to de-escalate violent situations have also not been validated. 18,19 The majority of these de-escalation courses were designed for other settings, such as correctional facilities, and then modified to apply to the health care or ED settings. Whether or not this is adequate in providing ED staff with the tools they need to effectively deal with WPV situations is not well- documented. 13,20 There has been limited literature that explores the experience of VWPV by itself, without the link to PWPV for the ED RN. Major themes from all VWPV studies include a sense that WPV is just "part of the job," reporting the incidents does not modify or influence future outcomes, and a feeling that the incidents will somehow be blamed on the RN. 21 Swearing, obscenity, and the threats of legal action have been the most consistently reported types of VWPV. 6,22–24 Not only does VWPV affect the RN, it also affects patient care. The Joint Commission 17 issued a sentinel event alert, acknowledging that disruptive and intimidating behaviors can lead to medical errors and poor patient care. It can also lead to increased turnover, which
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also contributes to decreased patient care, as that adds to organizational costs and less experienced nurses. The other important reason to address and manage VWPV effectively can be illuminated using concepts borrowed from Kelling and Coles Broken Windows theory. 25 When lower levels of violence or crime are tolerated, it signals an underlying acceptance of higher levels of violence, including violent crime. In the criminal justice literature, these disorderly conditions augment fear and lead to more verbal and physical incivilities. If a patient is verbally assaultive to the ED RN in triage, and nothing is done about effectively de-escalating the situation, that patient—or those who viewed the “successful” abuse of the ED RN—may continue to act out and either continue to verbally assault the nurse or move on to physical assault. Methods
The aim of this study was to explore the experience of VWPV directed at ED RNs from patients or family members. A grounded-theory methodology 26,27 was chosen to explore the experiences of individual participants and to produce a conceptual understanding of the data. DESIGN
Using grounded-theory methods, we studied ED RNs who had experienced VWPV, to explore experiences and feelings regarding VWPV from patients and their visitors. Grounded theory focuses on the identification, description, and explanation of various interactional processes among individuals and within groups that experience a given social context. 28 PARTICIPANTS
Participants were recruited through advertising in local hospitals and social networking sites. Snowball sampling then quickly filled the remaining necessary participants until saturation was achieved. The final participant total was 28. The university’s Institutional Review board approved this study, and the study was funded by a university-based grant. The participants gave informed consent and were aware that they could drop out of the study at any time and that their responses would be confidential and coded for anonymity. Names that appear in the discussion are fictitious and randomly assigned by the researchers. DATA COLLECTION
A total of 28 nonstructured, in-depth interviews were conducted with participants between June 2014 and June
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2015. The contents of the interviews were tape-recorded using a digital audio recording device, and the participant’s nonverbal responses were directly observed and written as field notes. The researchers set up appointments for times and sites that were convenient for the participants. Because of distance, 6 interviews were conducted by phone, and 2 were conducted using FaceTime on an iPhone. Questions included “Tell me about a time that you experienced verbal abuse or verbal workplace violence; how did that make you feel? What helps you come back to work for following shifts? What do you think contributes or relieves verbal workplace violence?” The participants were also encouraged to bring up their own ideas, thoughts, comments, and suggestions regarding VWPV, to which the interviewer would ask relevant follow-up and probing questions. Each interview lasted from 50 to130 minutes. Data collection was conducted simultaneously, and analysis continued until no new code emerged, and the data were considered saturated. NVivo 6 29 was used to aid with clarity and consistency of identifying patterns in the data. Through analyzing data by qualitative analysis, including the coding process, categories of decision regarding VWPV were generated. DATA ANALYSIS
A total of 28 participants completed the study. The average length of time spent in the emergency department as an RN was 11.07 years (SD = 5.44); 17 participants were female; 11 were male; and the educational levels of our participants included Associate Degree RN: 25% (n = 14), Bachelors in Nursing: 50% (n = 7), and Masters in Nursing: 25% (n = 7). Constant comparative data analysis was used, and all tape-recorded responses were transcribed verbatim by a professional transcription service and then verified by the researchers. All participants were assigned pseudonyms, and transcripts were checked to remove any information that might identify the information (references to specific physicians, hospitals, or coworkers). Grounded-theory principles and practices were used to collect and analyze the data. 27 Once the first interviews were transcribed, the first process of analysis was open coding, whereby initial codes were assigned to units of text (words, phrases, sentences, or sections of text). The codes at this stage were quite close to the data. Many middle order categories were then created, and some data were coded with more than one category. Patterns then arose from the data and relationships among categories, and codes were analyzed. Eventually, no new themes were discovered, and saturation was reached. Data from later interviews were then analyzed within the framework of the emerging categories.
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Results
The findings of this study revealed what was already well-known in the literature: that ED RNs routinely experience VWPV. However, the depth and frequency of the trauma of repeated exposure to VWPV and how it affects job satisfaction and performance, subsequent patient care, and relationship with peers was of interest. The overarching theme for all the subthemes was that of occupational disappointment (OD) and was a major theme in all 28 interviews. Occupational disappointment is the idea that RNs enter into this profession to help people and then are faced with a continued barrage of verbal abuse that disheartens nurses. Occupational disappointment may not be necessarily strong enough to influence RNs to leave the profession, but it does affect their satisfaction with their choice of career. The subthemes of this study were protective, contributing, and neutral factors to OD. Protective factors from experiencing higher levels of OD included the presence of “The Calmer” and protective relationships with nursing and physician peers. Contributing factors to OD included the presence of “The Escalator” and the general work environment of the emergency department, especially triage and unrealistic patient expectations. Neutral factors included the presence and involvement of management and questionable usefulness of mandatory behavior management classes. The general schematic of the study's findings can be seen in Figure 1. OCCUPATIONAL DISAPPOINTMENT
Participants routinely referenced a general feeling of being disheartened by how they were spoken to and treated by patients and their family members in the emergency department. Carol, with 15 years of experience in the emergency department, was asked how being spoken to in an abusive way made her feel. She said, “Awful. Awful. Because I went into nursing to help people, and that is what is really behind trying to help someone. When you go in to try to render help and care and they are nasty and awful to you, you kind of just throw up your shoulders and hands in the air and ask yourself, ‘Why am I even doing this?’ So it’s very frustrating. It makes you sort of question why you went into nursing at all.” Debra, with 25 years of experience, had a similar sentiment. “Yet they expect you to be that doting person to them after they rip you apart verbally. It’s just fascinating… I don’t know what other place in the world where they expect someone to take care of them and yet they can
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FIGURE 1 Framework for occupational disappointment.
destroy you verbally, and sometimes they try to attack you physically, and then they expect you to take care of them.” Robert, with 11 years of ED experience, said, “It’s just this feeling deep down, like, man, this isn’t how I thought being an ED nurse would be. I thought I would come in to help everyone and they’d be like, ‘hey, thanks!’ And instead, I get people calling me an a**hole because the wait is too long.” PROTECTING AND CONTRIBUTING INFLUENCES OF PEOPLE TO OD
Peers definitely influenced all the participants in negative or positive ways. There were specific types of nurses that came up in multiple interviews. These ED RN personality types were categorized into themes including “The Calmer,” “The Escalator,” and “The Protector.” The Calmer Study participants frequently referred to the presence of a fellow RN who was inherently well-suited for de-escalating verbally abusive patients or visitors. Participants stated that it was something this person “just had”; they did not think these traits could be learned or taught. Sandy, who has 6 years of experience as an ED RN, said: “One of our charge nurses is the ‘Zen’ of calm. He’s
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always absolutely wonderful. And it frustrates me, but, then—as angry as I am that he spoke to them—I’m glad that he diffused the situation, even though they talked badly to me, and I don’t feel they deserved the respect. But it solved the situation on the patient’s end…he’s like a Jedi mind master…he must’ve just been born with it.” Joe, 13 years as an ED RN, said: “We have this one nurse who is just a soothing person. She is never in a bad mood or angry. She can de-escalate any situation.” The Escalator The “Escalator” is a person continuously described as an ED RN who would make the situation worse on a routine basis. Eugene, 7 years as an ED RN, said: “…she was getting that patient so fired up, and it didn’t have to go that way. So when she’s in first-tier triage, and someone asks how long it will be, she says she just can’t give them any idea at all, so she’s already starting the relationship off in the wrong way…” Andrea, 4 years as an ED RN, said: “There are certain people who shouldn’t be placed in triage because they are not in a happy place, or they’ve been doing it for too long, or they have no filter, like, who you need to be stern with, or they will be mean to the person who has never been to the ER, or, you know, absolutely innocent, and then go off on the patient.” Sue, 15 years as an ED RN, said: “Right. I think it’s a personality thing. You know, there’s the angry…person …
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they just don’t have that self-awareness or they are just not happy or they’re wanting to pick a fight.” Mike, 12 years as an ED RN, said: “I remember this one time a patient punched this RN in the face. Not that was okay or anything, but, in my opinion, she was kind of provoking the patient.” The Protector The last category of recurring personality categories was “The Protector.” This is the RN who steps in and either takes over for an RN who is experiencing a challenging patient or intervenes for another nurse who might be newer or more timid. Melanie, 6 years as an ED RN, said: “So, ‘K’ is really good at helping and setting boundaries with rude patients. She has been there a long time, so she doesn’t let patients get away with taking advantage of the newer or more quiet nurses. She’s not mean about it or anything. She just doesn’t take any crap.” Scott, 18 years as an ED RN, said: “We have a couple nurses who just stand up, you know, for the weaker nurses who can get picked on by certain patients. They will just step in and take over the assignment or whatever they can do to help, but in a positive way.” The environment of the ED also had multiple contributing factors to OD. The area of triage was a specific location that came up routinely. Twenty-six out of the 28 RNs interviewed said triage was where they faced the most VWPV. The VWPV in triage occurred regardless of time of day or shift (day or night). Eric, with 9 years of experience as an ED RN, said: “It starts in triage and it continues all the way through. Because you try to manage the people who are in the waiting room, who don’t want to be in the waiting room, and they see other people go on in ahead of them, and they are infuriated, and they don’t understand the concept of triage, and it doesn’t matter if you try to explain it to them; it is all in their own self needs. And, at some point, you can understand it, the person, you don’t want to have to wait there and its your own personal emergency happening, but it is exhausting for everyone to be pissed off at you.” Charlie, 13 years as an ED RN, said: “Triage is fine if there is zero wait. Anything other than that…the verbal insults are flying. It is exhausting.” Presence of Security The presence and quality of hospital security guards was also a point of scrutiny in the interviews. Bruce, 12 years as an ED RN, said: “Having real security guards would help, not the one who is 90 pounds
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soaking wet. Or the guy who you can hear him breathe from across the room. County has actual cops, they have the sheriffs. That would help, too: just having the physical presence. They look at our security and they’re like oh, yeah, look at that rent-a-cop. Having real law enforcement with badges and armed weapons: just the face value. People don’t usually act out when they see that.” Dan, 10 years as an ED RN: “Our security is usually, not to be mean, but, lacking in the strong department. We usually rely on us bigger males to take care of the problem patients. When none of us (guys) are working, sometimes things get more out of hand, the female nurses have said. Maybe patients go from mouthing off to being physical if they don’t think anyone is around to do anything about it.” Raquel, 3 years as an ED RN: “We have security 24 hours a day in triage. Some are better than others: just like nurses, I guess. Some will really try to talk the patient down; some just go on a power trip.” NEUTRAL INFLUENCES TO OD
Management The presence and influence of management did not seem to be a positive or negative influence in the mitigation of VWPV. Participants discussed—similar to inherent personality traits of fellow nurses—that some managers were better suited for de-escalating patient behavior. Cindy, 17 years as an ED RN: “Management tries to help. I get where they are coming from. They want to make everyone happy, which is impossible.” David, 14 years as an ED RN: “I have asked for management to come deal with an abusive patient. I guess it depends on who is on duty [as to] what you’ll get. Some managers will just give the patient whatever they want so they’re happy, and some will stick up for the nurses. I’m not really sure which one is better, actually.” Eugene: “When you ask for management, you also have to ask yourself, what do you expect them to do? Kick the patient out? Yell back at the visitor? Yeah, clear expectations is needed or everyone is frustrated.” Mandatory Courses All ED RNs who were interviewed were working in California, where state law requires all ED staff to take some type of behavior-modification course. Most ED RNs thought that the classes they were forced to take were not effective or had little efficacy in successfully de-escalating patient behaviors. Most ED RNs cited a lack of time to implement the tools taught in these classes.
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Scott, 18 years as an ED RN: “The classes help a little bit, but the problem is maybe it helps you at 7:30 in the morning when you are fresh and you have energy, but after you’ve seen your 40 th patient of the day, and your nerves are fried, sometimes that wins out, and you go back to your reactive self… I think ‘the class’ gives you some tools, but sometimes, in the heat of the moment, you forget those tools.” Jerry, 3 years as an ED RN: “I mean, the stuff they teach us seems like it might help if I had 20 minutes for each patient. But you might have two traumas coming in, an MI patient, a stroke patient, etc, you don’t have the luxury of that time.”
Discussion
This study explored the experiences of VWPV in ED RNs and highlighted some important issues. One of the most fundamental findings was that of what these researchers are calling occupational disappointment (OD). This is different from compassion fatigue (CF) or burnout syndrome (BOS). Compassion fatigue and BOS are often used interchangeably, but there are subtle differences. 30,31 Compassion fatigue is usually more abrupt and is a result of being exposed to someone else’s trauma. Compassion fatigue can lead to problems mentally and physically such as anxiety, sleeplessness, and anger. Burnout or BOS could be considered a more chronic reaction to repeated stressful exposures in which interactions are expected to be empathetic and can lead to long-term exhaustion and diminished interest. 31 Occupational disappointment appears to be conceptually different from CF and BOS in a few ways: The negative stimulus is not necessarily considered to be traumatic and is directed personally to the RN. The verbal abuse is not being experienced second hand, as CF, but instead is directed intentionally to the RN. Also, in our study, the RNs were not reporting that the VWPV was a catalyst for changing careers or quitting but more of a chronic annoyance that could be counterbalanced by nicer patients. Finally, OD presented itself in a melancholy attitude that expresses disappointment with what they had expected emergency nursing to be. This is similar to the concepts of Kramer’s Reality Shock but specific to an environment and not nursing in general. Kramer described how the discrepancies between the nursing school environment and the actual practice environment differed and left newer nurses with a feeling of distress and dissatisfaction. 32 Another finding is the perception of certain personality traits that are well-suited or poorly suited for addressing conflicts. These personality types were named “The Calmer,” “The Escalator,” and “The Protector.” Every nurse who was interviewed recounted a story of at least one of these personality types, if not all three. Mandatory courses should address these personality types and try to give each type of person a specific
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set of tools to identify and attempt to de-escalate a patient who is becoming aggressive or angry. Although personality traits are inherent and can be difficult to modify, successfully identifying useful or maladaptive tendencies could make a smoother experience for all who work in and use the ED. ENVIRONMENT
The environment of the emergency department was problematic, especially triage. Triage was cited by all participants as the most frequent location of VWPV in the emergency department. Patient expectations, unfamiliarity with the triage process, and long waits compounded the issue of VWPV. Longer shifts in triage seemed for some to be a contributing factor to the nurse’s frustration, but this was not true for all nurses. Again, it seemed some personalities were better suited for the challenges of triage than others. SECURITY
Literature supports the presence of security to de-escalate problematic situations, but our research found that the mere presence of security was not necessarily helpful. Security guards had to have the ability and presence to perform their duties in acute situations. They must also have the personality traits to de-escalate situations rather than engaging in power battles with patients. Our participants stated that security guards also needed to possess a strong presence to be effective. At times, the security guards assigned to emergency departments were not up to par in the participants’ eyes, and nurses felt they were alone or without backup help. MANAGEMENT
Management seemed to be a neutral subtheme in this study. Most participants found them neither helpful nor unhelpful. Most participants who did not find management helpful stated that they usually did not ask for their help because of the perception that there was nothing that could be done anyway. Perhaps management should make a concerted effort to engage with staff and patients to ascertain ways that might make their presence known or make what they are able to offer staff better known. Some managers were perceived to be effective in de-escalating situations, but this was not a consistent finding. MANDATORY CLASSES
There are multiple types of behavior management courses available to emergency departments. Participants in this study named 3 separate courses, and all had similar experiences with them. The main observation by participants was that the courses have limited usefulness in a time-pressed environment such as
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the emergency department. If the staff had unlimited time to interact with patients, the likelihood of VWPV would decrease. This is not realistic in any ED situation. These classes were not designed for the acute, chaotic ED environment, in which time is severely limited. This leaves staff with a dearth of necessary tools in their de-escalation tool belts. Also, further research should critically evaluate classes that are offered that purport to give staff tools to deal with VWPV but, in actuality, may be contributing to staff frustration and feelings of inadequacy. Future development of behavior management courses should be focused on how best to implement tools under severe time pressures and how to avoid the escalation of problems between nurses and patients in the first place. Education of patients before coming to the emergency department, perhaps by their primary medical physicians, regarding standard wait times and procedures is recommended. There should be resources available in triage to explain the process and keep patients updated and perhaps even a dedicated resource nurse that has no patient assignment to watch for and intervene when a situation does begin to escalate. Identifying personality traits that can be helpful or harmful that can be modified might also be useful in these types of courses. Protective factors include an affinity for the pace and environment of the emergency department but more for the people with whom one works. We should focus on these protective factors, including fostering and nurturing peer relationships and communication. Perhaps sponsoring employee bonding events and even staff meals may continue to foster and build ED staff member relationships and offset feelings of OD. Mitigating the feelings of OD may contribute to happier, more fulfilled staff members and may reverse the negative cycle and ease the frustrations of ED RNs.
Limitations
There were a few limitations to this study. All participants were from the West Coast and may not be representative of all ED RNs. Many of the participants worked in busy trauma centers, which may also influence the generalizability to ED RNs who work in smaller hospitals without official trauma designation. Journaling and self-reflection were employed throughout the interviews; however, on some level, the perceptions and ideas of the researcher surely influenced the data analysis.
Implications of Findings to ED Nursing Practice
There are numerous implications of these findings to ED Nursing Practice, although—as with any grounded-theory
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study—more research is needed to develop the central tenets of this study. Hospital administrators, nursing educators, and formal nursing agencies should be aware of—and discuss—OD with new and seasoned nurses alike. Areas that are causative of OD should be mitigated when possible, and areas that are protective should be supported. At times, advocacy groups and formal position papers from regulatory and representative agencies place heavy focus on managerial support. This study demonstrates that managerial support is a neutral factor in OD and not as important as peer support, which was found to be a protective factor. Therefore, more attention should be placed on fostering positive and beneficial peer relationships such as staff lunches, extracurricular activities, placing peer-identified supportive staff members in triage together, and other ideas as suggested by staff members themselves. Emergency department RNs and educators should focus on re-evaluating current mandatory de-escalation or behavior management courses for efficacy. Continued input into these courses is necessary and perhaps even the development of new courses specifically designed for the challenges the ED RN encounters daily. More “just in time” tools should be available for the ED RN in the time-sensitive environment of the ED.
Conclusions
Although OD may seem disheartening, the authors would like to end on a more positive note. Study participants often discussed the positive and protective influence of “nice” patients, peers, and physician colleagues. Paula, with 23 years’ experience, said: "Having said that, of course, it’s the mean ones who make the most impression, but most people are normal human beings, and that’s the saving grace because if it really was every single person, you just couldn’t do the job. You are so grateful for these people. I tell patients that all the time. I say ‘thank you so much.’" Katie, with 11 years of ED experience: "It doesn’t even have to be exceptional, but just like I said, even a mere thank you, it really ties it all together. I really feel that nursing is my calling in life. When I have a day like that, a good day, quote, unquote— “a good day”—I feel complete. I feel blissful.” Agnes, with 13 years of ED experience: "Because as much as there are people who are not appreciative or rude, there are the people who are appreciative and are kind and sweet, you know. There are nice people. The good outweigh the bad. Because, you know, it wouldn’t be fair to the people who deserve your care or who are appreciative not to
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have you be there or have an attitude if you let all the bad stuff weigh you down. Yeah, the nice people keep me going." Verbal WPV does not hold true to the old childhood rhyme "Sticks and stones will break my bones, but words will never hurt me." Indeed, words hurt, and VWPV is considered a form of psychological abuse that has persistent negative effects. Certainly, more research is needed to validate this study's findings and continue to explore factors contributing to OD. More research is also needed to develop a course to address VWPV, PWPV, and useful de-escalation techniques in a time-limited environment. Subtle support changes, such as modifying the triage environment and encouraging staff relationships, may also decrease feelings of OD. These modifications and support may serve to break the negative cycle of ED RNs carrying over negative experiences from one patient to another and may help create a calmer atmosphere in a sea of ED chaos.
REFERENCES 1. OSHA. Safety and Health Topics: Workplace Violence. 2. Nurses ICo. Nursing Matters. Violence: A Worldwide Epidemic. 3. Association EN. Violence in the Emergency Department: Findings from ENA's study of Workplace Violence Against Registered Nurses. 4. Ryan D, Maguire J. Aggression and violence: a problem in Irish accident and emergency departments?. J Nurs Manag. 2006;14:105-116. 5. Gates DM, Ross CS, McQueen L. Violence against emergency department workers. J Emerg Med. 2006;31(3):331-337. 6. Crilly J, Charboyer W, Creedy D. Violence towards emergency nurses by patients. Accid Emerg Nurs. 2004;12:67-73. 7. Taylor JL, Rew L. A systematic review of the literature: workplace violence in the emergency department. J Clin Nurs. 2011;20(7-8):1072-1085. 8. Special report. NIOSH: new facts about violence against healthcare workers and security officers. Hosp Secur Saf Manage. 1996;17(5):5-9. 9. Child RJ, Mentes JC. Violence against women: the phenomenon of workplace violence against nurses. Issues Ment Health Nurs. 2010;31(2):89-5. 10. Sato K, Wakabayashi T, Kiyoshi-Teo H, Fukahori H. Factors associated with nurses' reporting of patients' aggressive behavior: a cross-sectional survey. Int J Nurs Stud. 2013;50(10):1368-1376. 11. Gates DM, Gillespie GL, Succop P. Violence against nurses and its impact on stress and productivity. Nurs Econ. 2011;29(2):59-66. quiz 67. 12. Gillespie GL, Bresler S, Gates DM, Succop P. Posttraumatic stress symptomatology among emergency department workers following workplace aggression. Workplace Health Saf. 2013;61(6):247-254. 13. Gillespie G, Gates D, Miller M, Howard P. Violence against healthcare workers in a pediatric emergency department. Adv Emerg Nurs J. 2010;32(1):68-82.
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14. Knott JC, Bennett D, Rawet J, Taylor DM. Epidemiology of unarmed threats in the emergency department. Emerg Med Australas. 2005;17(4):351-358. 15. Gacki-Smith J, Juarez AM, Boyett L, Homeyer C, Robinson L, MacLean SL. Violence against nurses working in US emergency departments. J Nurs Adm. 2009;39(7-8):340-349. 16. Papa A, Venella J. Workplace violence in healthcare: strategies for advocacy. Online J Issues Nurs. 2013;18(1):5. 17. The Joint Commission. Code black and blue: why patients turn violent and how to recognize it before it happens. Available at: https://www. jointcommission.org/assets/1/6/Code_Black_Blue_EoC_News_Vol_18_ No__1_Jan_2015.pdf. Accessed July 11, 2017. 18. Peek-Asa C, Casteel C, Allareddy V, et al. Workplace violence prevention programs in hospital emergency departments. J Occup Environ Med. 2007;49(7):756-763. 19. Gillespie GL, Gates DM, Mentzel T, Al-Natour A, Kowalenko T. Evaluation of a comprehensive ED violence prevention program. J Emerg Nurs. 2013;39(4):376-383. 20. Songer T, Stephens-Stidham S, Peek-Asa C, et al. Core competencies for injury and violence prevention. Am J Public Health. 2009;99(4):600-606. 21. Heick R, Young T, Peek-Asa C. Occupational injuries among emergency medical service providers in the United States. J Occup Environ Med. 2009;51(8):963-968. 22. Stone TE, McMillan M, Hazelton M. Swearing: its prevalence in healthcare settings and impact on nursing practice. J Psychiatr Ment Health Nurs. 2010;17(6):528-534. 23. Stone T, McMillan M, Hazelton M, Clayton EH. Wounding words: swearing and verbal aggression in an inpatient setting. Perspect Psychiatr Care. 2011;47(4):194-203. 24. Pich J, Hazelton M, Kable A. Violent behaviour from young adults and the parents of paediatric patients in the emergency department. Int Emerg Nurs. 2013;21(3):157-162. 25. Kelling G, Coles C. Fixing Broken Windows, New York: Simon and Schuster; 1996. 26. Lewis LF. Putting 'quality' in qualitative research: a guide to grounded theory for mental health nurses. J Psychiatr Ment Health Nurs. 2015;22(10) 821-828. 27. Glaser B, Strauss A. The Discovery of Grounded Theory: Strategies for Qualitative Research, Chicago: Aldine Publishing Company; 1967. 28. Ghezeljeh T, Emami A. Grounded Theory: methodology and philosophical perspective. Nurse Res. 2009;17(1):15-23. 29. 2010 QI. NVivo 8 Tutorials. www.qsrinternational.com/support_tutorials. Aspx?product=18. 30. Sorenson C, Bolick B, Wright K, Hamilton R. Understanding compassion fatigue in healthcare providers: a review of current literature. J Nurs Scholarsh. 2016;48(5):456-465. 31. Berg GM, Harshbarger JL, Ahlers-Schmidt CR, Lippoldt D. Exposing compassion fatigue and burnout syndrome in a trauma team: a qualitative study. J Trauma Nurs. 2016;23(1):3-10. 32. Kramer M. The new graduate speaks. Am J Nurs. 1996;66(11):2420-2424
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OCCUPATIONAL DISAPPOINTMENT: WHY DID I EVEN BECOME A NURSE? Authors: Rebekah J. Howerton Child, PhD, RN, and Elizabeth J. Sussman, PhD, RD, Northridge, CA
Contribution to Emergency Practice:
• This research is new, as—to the researchers’ knowledge— very little research using grounded-theory methodology has been done about verbal workplace violence (VWPV) in emergency departments in the United States. • Although the emergency nursing society is well aware of the problem of workplace violence, this study illuminates some new and interesting themes that will contribute information to the practice of emergency nursing. These themes include occupational disappointment and specific personality types that can prevent or de-escalate workplace violence. • Translation of this article’s findings to emergency nursing practice includes discussing occupational disappointment with both new and seasoned nurses. Protective and causative factors should be identified internally and addressed as needed. • Identifying specific personality types among staff members might be useful in protecting nurses from the deleterious effects of VWPV. • Emergency departments need consistently to evaluate and re-evaluate mandatory violence prevention courses that are provided by hospitals and that ensure nurses are being provided “real time” tools for proper management of VWPV.
orkplace violence of all types in the emergency department is a current focus of literature and development of policies and procedures. Numerous regulatory and professional agencies have placed workplace violence (WPV) on research agendas and group
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Rebekah J. Howerton Child, is Assistant Professor, Department of Nursing, California State University, Northridge, CA. Elizabeth J. Sussman, is Assistant Professor and Graduate Coordinator, Department of Family and Consumer Sciences, California State University, Northridge, CA. For correspondence, write: Rebekah J. Howerton Child, PhD, RN, 18111 Nordhoff Street, Northridge, CA 91330-8303; E-mail: [email protected]. J Emerg Nurs ■. 0099-1767 Copyright © 2017 Emergency Nurses Association. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jen.2017.06.004
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Abstract Introduction: The aim of this study was to identify patterns of
feelings and behavior of ED RNs who have experienced verbal workplace violence. Methods: Twenty-eight registered nurses from across the
state of California were recruited. Data were collected, using in-depth interviews, and were recorded. The tapes were transcribed and analyzed using Glaserian grounded-theory methodology. Results: The main experiences of participants included occupational disappointment, peer support, lack of preparation by mandatory violence prevention classes, and unrealistic patient expectations. Discussion: These findings can help staff, managers, and
future educators of ED RNs examine feelings, mitigate the profound and pervasive effects of VWPV, and improve patient care. Key Words: Workplace violence; Emergency nursing; Grounded
theory; Occupational disappointment
statements, including The Joint Commission (TJC), the American College of Emergency Physicians, the American Nurses Association, the Emergency Nurses Association (ENA), The Occupational Safety and Health Administration, and the National Institute for Occupational Safety and Health. The Occupational Safety and Health Administration defines WPV as "any act or threat of physical violence, harassment, intimidation, or other threatening disruptive behavior that occurs at the work site. It ranges from threats and verbal abuse to physical assaults and even homicide." 1
Background
Those working in the health care profession are expected to help people; therefore, it is counterintuitive that health care workers are more likely to be attacked than police officers or
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prison guards 2 and that health care workers account for 48% of all nonfatal injuries from workplace assaults. 1 The estimated incidence of physical WPV (PWPV) ranged from 42% to 72% in a 6- to 12-month period in various studies. 3 Other studies have reported a staggering statistic that 99% of ED RNs have experienced verbal WPV (VWPV) within a 3-month period. 3–7 These estimates are generally considered to be on the low side, as the majority of WPV remains grossly underreported. 3 The effects of WPV are far reaching and produce a heavy financial and emotional burden. Days off work, workers’ compensation claims, staff turnover, and other various medical and legal expenses are estimated to cost billions annually. 7–9 The emotional burden of violence of both types (physical and verbal) can lead to negative effects for both the ED RN and, subsequently, the patient care they render. 10–12 Decreased or negative coping skills may lead to substance abuse, increased absenteeism, stress, anxiety, and intent to leave. 13 The emergency department is at highest risk for WPV of any type, owing to its ease of access by the public, 24-hour availability, perceived chaos, acute nature of patients’ physical complaints, and high levels of stress by those who visit emergency departments for their health care needs. Also, the degree to which emergency departments see acutely intoxicated and psychotic patients also increases the levels and types of WPV. 3,14–16 The efficacy of policies, procedures, and programs to mitigate all types of WPV prevention programs has not been well-established. Implementing a "Zero Tolerance" policy has been recommended by the ENA and TJC, but whether or not these policies are effective in reducing violence is unknown at this time. 3,17 Mandatory classes that ED staff may take to provide tools to de-escalate violent situations have also not been validated. 18,19 The majority of these de-escalation courses were designed for other settings, such as correctional facilities, and then modified to apply to the health care or ED settings. Whether or not this is adequate in providing ED staff with the tools they need to effectively deal with WPV situations is not well- documented. 13,20 There has been limited literature that explores the experience of VWPV by itself, without the link to PWPV for the ED RN. Major themes from all VWPV studies include a sense that WPV is just "part of the job," reporting the incidents does not modify or influence future outcomes, and a feeling that the incidents will somehow be blamed on the RN. 21 Swearing, obscenity, and the threats of legal action have been the most consistently reported types of VWPV. 6,22–24 Not only does VWPV affect the RN, it also affects patient care. The Joint Commission 17 issued a sentinel event alert, acknowledging that disruptive and intimidating behaviors can lead to medical errors and poor patient care. It can also lead to increased turnover, which
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also contributes to decreased patient care, as that adds to organizational costs and less experienced nurses. The other important reason to address and manage VWPV effectively can be illuminated using concepts borrowed from Kelling and Coles Broken Windows theory. 25 When lower levels of violence or crime are tolerated, it signals an underlying acceptance of higher levels of violence, including violent crime. In the criminal justice literature, these disorderly conditions augment fear and lead to more verbal and physical incivilities. If a patient is verbally assaultive to the ED RN in triage, and nothing is done about effectively de-escalating the situation, that patient—or those who viewed the “successful” abuse of the ED RN—may continue to act out and either continue to verbally assault the nurse or move on to physical assault. Methods
The aim of this study was to explore the experience of VWPV directed at ED RNs from patients or family members. A grounded-theory methodology 26,27 was chosen to explore the experiences of individual participants and to produce a conceptual understanding of the data. DESIGN
Using grounded-theory methods, we studied ED RNs who had experienced VWPV, to explore experiences and feelings regarding VWPV from patients and their visitors. Grounded theory focuses on the identification, description, and explanation of various interactional processes among individuals and within groups that experience a given social context. 28 PARTICIPANTS
Participants were recruited through advertising in local hospitals and social networking sites. Snowball sampling then quickly filled the remaining necessary participants until saturation was achieved. The final participant total was 28. The university’s Institutional Review board approved this study, and the study was funded by a university-based grant. The participants gave informed consent and were aware that they could drop out of the study at any time and that their responses would be confidential and coded for anonymity. Names that appear in the discussion are fictitious and randomly assigned by the researchers. DATA COLLECTION
A total of 28 nonstructured, in-depth interviews were conducted with participants between June 2014 and June
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2015. The contents of the interviews were tape-recorded using a digital audio recording device, and the participant’s nonverbal responses were directly observed and written as field notes. The researchers set up appointments for times and sites that were convenient for the participants. Because of distance, 6 interviews were conducted by phone, and 2 were conducted using FaceTime on an iPhone. Questions included “Tell me about a time that you experienced verbal abuse or verbal workplace violence; how did that make you feel? What helps you come back to work for following shifts? What do you think contributes or relieves verbal workplace violence?” The participants were also encouraged to bring up their own ideas, thoughts, comments, and suggestions regarding VWPV, to which the interviewer would ask relevant follow-up and probing questions. Each interview lasted from 50 to130 minutes. Data collection was conducted simultaneously, and analysis continued until no new code emerged, and the data were considered saturated. NVivo 6 29 was used to aid with clarity and consistency of identifying patterns in the data. Through analyzing data by qualitative analysis, including the coding process, categories of decision regarding VWPV were generated. DATA ANALYSIS
A total of 28 participants completed the study. The average length of time spent in the emergency department as an RN was 11.07 years (SD = 5.44); 17 participants were female; 11 were male; and the educational levels of our participants included Associate Degree RN: 25% (n = 14), Bachelors in Nursing: 50% (n = 7), and Masters in Nursing: 25% (n = 7). Constant comparative data analysis was used, and all tape-recorded responses were transcribed verbatim by a professional transcription service and then verified by the researchers. All participants were assigned pseudonyms, and transcripts were checked to remove any information that might identify the information (references to specific physicians, hospitals, or coworkers). Grounded-theory principles and practices were used to collect and analyze the data. 27 Once the first interviews were transcribed, the first process of analysis was open coding, whereby initial codes were assigned to units of text (words, phrases, sentences, or sections of text). The codes at this stage were quite close to the data. Many middle order categories were then created, and some data were coded with more than one category. Patterns then arose from the data and relationships among categories, and codes were analyzed. Eventually, no new themes were discovered, and saturation was reached. Data from later interviews were then analyzed within the framework of the emerging categories.
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Results
The findings of this study revealed what was already well-known in the literature: that ED RNs routinely experience VWPV. However, the depth and frequency of the trauma of repeated exposure to VWPV and how it affects job satisfaction and performance, subsequent patient care, and relationship with peers was of interest. The overarching theme for all the subthemes was that of occupational disappointment (OD) and was a major theme in all 28 interviews. Occupational disappointment is the idea that RNs enter into this profession to help people and then are faced with a continued barrage of verbal abuse that disheartens nurses. Occupational disappointment may not be necessarily strong enough to influence RNs to leave the profession, but it does affect their satisfaction with their choice of career. The subthemes of this study were protective, contributing, and neutral factors to OD. Protective factors from experiencing higher levels of OD included the presence of “The Calmer” and protective relationships with nursing and physician peers. Contributing factors to OD included the presence of “The Escalator” and the general work environment of the emergency department, especially triage and unrealistic patient expectations. Neutral factors included the presence and involvement of management and questionable usefulness of mandatory behavior management classes. The general schematic of the study's findings can be seen in Figure 1. OCCUPATIONAL DISAPPOINTMENT
Participants routinely referenced a general feeling of being disheartened by how they were spoken to and treated by patients and their family members in the emergency department. Carol, with 15 years of experience in the emergency department, was asked how being spoken to in an abusive way made her feel. She said, “Awful. Awful. Because I went into nursing to help people, and that is what is really behind trying to help someone. When you go in to try to render help and care and they are nasty and awful to you, you kind of just throw up your shoulders and hands in the air and ask yourself, ‘Why am I even doing this?’ So it’s very frustrating. It makes you sort of question why you went into nursing at all.” Debra, with 25 years of experience, had a similar sentiment. “Yet they expect you to be that doting person to them after they rip you apart verbally. It’s just fascinating… I don’t know what other place in the world where they expect someone to take care of them and yet they can
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FIGURE 1 Framework for occupational disappointment.
destroy you verbally, and sometimes they try to attack you physically, and then they expect you to take care of them.” Robert, with 11 years of ED experience, said, “It’s just this feeling deep down, like, man, this isn’t how I thought being an ED nurse would be. I thought I would come in to help everyone and they’d be like, ‘hey, thanks!’ And instead, I get people calling me an a**hole because the wait is too long.” PROTECTING AND CONTRIBUTING INFLUENCES OF PEOPLE TO OD
Peers definitely influenced all the participants in negative or positive ways. There were specific types of nurses that came up in multiple interviews. These ED RN personality types were categorized into themes including “The Calmer,” “The Escalator,” and “The Protector.” The Calmer Study participants frequently referred to the presence of a fellow RN who was inherently well-suited for de-escalating verbally abusive patients or visitors. Participants stated that it was something this person “just had”; they did not think these traits could be learned or taught. Sandy, who has 6 years of experience as an ED RN, said: “One of our charge nurses is the ‘Zen’ of calm. He’s
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always absolutely wonderful. And it frustrates me, but, then—as angry as I am that he spoke to them—I’m glad that he diffused the situation, even though they talked badly to me, and I don’t feel they deserved the respect. But it solved the situation on the patient’s end…he’s like a Jedi mind master…he must’ve just been born with it.” Joe, 13 years as an ED RN, said: “We have this one nurse who is just a soothing person. She is never in a bad mood or angry. She can de-escalate any situation.” The Escalator The “Escalator” is a person continuously described as an ED RN who would make the situation worse on a routine basis. Eugene, 7 years as an ED RN, said: “…she was getting that patient so fired up, and it didn’t have to go that way. So when she’s in first-tier triage, and someone asks how long it will be, she says she just can’t give them any idea at all, so she’s already starting the relationship off in the wrong way…” Andrea, 4 years as an ED RN, said: “There are certain people who shouldn’t be placed in triage because they are not in a happy place, or they’ve been doing it for too long, or they have no filter, like, who you need to be stern with, or they will be mean to the person who has never been to the ER, or, you know, absolutely innocent, and then go off on the patient.” Sue, 15 years as an ED RN, said: “Right. I think it’s a personality thing. You know, there’s the angry…person …
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they just don’t have that self-awareness or they are just not happy or they’re wanting to pick a fight.” Mike, 12 years as an ED RN, said: “I remember this one time a patient punched this RN in the face. Not that was okay or anything, but, in my opinion, she was kind of provoking the patient.” The Protector The last category of recurring personality categories was “The Protector.” This is the RN who steps in and either takes over for an RN who is experiencing a challenging patient or intervenes for another nurse who might be newer or more timid. Melanie, 6 years as an ED RN, said: “So, ‘K’ is really good at helping and setting boundaries with rude patients. She has been there a long time, so she doesn’t let patients get away with taking advantage of the newer or more quiet nurses. She’s not mean about it or anything. She just doesn’t take any crap.” Scott, 18 years as an ED RN, said: “We have a couple nurses who just stand up, you know, for the weaker nurses who can get picked on by certain patients. They will just step in and take over the assignment or whatever they can do to help, but in a positive way.” The environment of the ED also had multiple contributing factors to OD. The area of triage was a specific location that came up routinely. Twenty-six out of the 28 RNs interviewed said triage was where they faced the most VWPV. The VWPV in triage occurred regardless of time of day or shift (day or night). Eric, with 9 years of experience as an ED RN, said: “It starts in triage and it continues all the way through. Because you try to manage the people who are in the waiting room, who don’t want to be in the waiting room, and they see other people go on in ahead of them, and they are infuriated, and they don’t understand the concept of triage, and it doesn’t matter if you try to explain it to them; it is all in their own self needs. And, at some point, you can understand it, the person, you don’t want to have to wait there and its your own personal emergency happening, but it is exhausting for everyone to be pissed off at you.” Charlie, 13 years as an ED RN, said: “Triage is fine if there is zero wait. Anything other than that…the verbal insults are flying. It is exhausting.” Presence of Security The presence and quality of hospital security guards was also a point of scrutiny in the interviews. Bruce, 12 years as an ED RN, said: “Having real security guards would help, not the one who is 90 pounds
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soaking wet. Or the guy who you can hear him breathe from across the room. County has actual cops, they have the sheriffs. That would help, too: just having the physical presence. They look at our security and they’re like oh, yeah, look at that rent-a-cop. Having real law enforcement with badges and armed weapons: just the face value. People don’t usually act out when they see that.” Dan, 10 years as an ED RN: “Our security is usually, not to be mean, but, lacking in the strong department. We usually rely on us bigger males to take care of the problem patients. When none of us (guys) are working, sometimes things get more out of hand, the female nurses have said. Maybe patients go from mouthing off to being physical if they don’t think anyone is around to do anything about it.” Raquel, 3 years as an ED RN: “We have security 24 hours a day in triage. Some are better than others: just like nurses, I guess. Some will really try to talk the patient down; some just go on a power trip.” NEUTRAL INFLUENCES TO OD
Management The presence and influence of management did not seem to be a positive or negative influence in the mitigation of VWPV. Participants discussed—similar to inherent personality traits of fellow nurses—that some managers were better suited for de-escalating patient behavior. Cindy, 17 years as an ED RN: “Management tries to help. I get where they are coming from. They want to make everyone happy, which is impossible.” David, 14 years as an ED RN: “I have asked for management to come deal with an abusive patient. I guess it depends on who is on duty [as to] what you’ll get. Some managers will just give the patient whatever they want so they’re happy, and some will stick up for the nurses. I’m not really sure which one is better, actually.” Eugene: “When you ask for management, you also have to ask yourself, what do you expect them to do? Kick the patient out? Yell back at the visitor? Yeah, clear expectations is needed or everyone is frustrated.” Mandatory Courses All ED RNs who were interviewed were working in California, where state law requires all ED staff to take some type of behavior-modification course. Most ED RNs thought that the classes they were forced to take were not effective or had little efficacy in successfully de-escalating patient behaviors. Most ED RNs cited a lack of time to implement the tools taught in these classes.
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Scott, 18 years as an ED RN: “The classes help a little bit, but the problem is maybe it helps you at 7:30 in the morning when you are fresh and you have energy, but after you’ve seen your 40 th patient of the day, and your nerves are fried, sometimes that wins out, and you go back to your reactive self… I think ‘the class’ gives you some tools, but sometimes, in the heat of the moment, you forget those tools.” Jerry, 3 years as an ED RN: “I mean, the stuff they teach us seems like it might help if I had 20 minutes for each patient. But you might have two traumas coming in, an MI patient, a stroke patient, etc, you don’t have the luxury of that time.”
Discussion
This study explored the experiences of VWPV in ED RNs and highlighted some important issues. One of the most fundamental findings was that of what these researchers are calling occupational disappointment (OD). This is different from compassion fatigue (CF) or burnout syndrome (BOS). Compassion fatigue and BOS are often used interchangeably, but there are subtle differences. 30,31 Compassion fatigue is usually more abrupt and is a result of being exposed to someone else’s trauma. Compassion fatigue can lead to problems mentally and physically such as anxiety, sleeplessness, and anger. Burnout or BOS could be considered a more chronic reaction to repeated stressful exposures in which interactions are expected to be empathetic and can lead to long-term exhaustion and diminished interest. 31 Occupational disappointment appears to be conceptually different from CF and BOS in a few ways: The negative stimulus is not necessarily considered to be traumatic and is directed personally to the RN. The verbal abuse is not being experienced second hand, as CF, but instead is directed intentionally to the RN. Also, in our study, the RNs were not reporting that the VWPV was a catalyst for changing careers or quitting but more of a chronic annoyance that could be counterbalanced by nicer patients. Finally, OD presented itself in a melancholy attitude that expresses disappointment with what they had expected emergency nursing to be. This is similar to the concepts of Kramer’s Reality Shock but specific to an environment and not nursing in general. Kramer described how the discrepancies between the nursing school environment and the actual practice environment differed and left newer nurses with a feeling of distress and dissatisfaction. 32 Another finding is the perception of certain personality traits that are well-suited or poorly suited for addressing conflicts. These personality types were named “The Calmer,” “The Escalator,” and “The Protector.” Every nurse who was interviewed recounted a story of at least one of these personality types, if not all three. Mandatory courses should address these personality types and try to give each type of person a specific
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set of tools to identify and attempt to de-escalate a patient who is becoming aggressive or angry. Although personality traits are inherent and can be difficult to modify, successfully identifying useful or maladaptive tendencies could make a smoother experience for all who work in and use the ED. ENVIRONMENT
The environment of the emergency department was problematic, especially triage. Triage was cited by all participants as the most frequent location of VWPV in the emergency department. Patient expectations, unfamiliarity with the triage process, and long waits compounded the issue of VWPV. Longer shifts in triage seemed for some to be a contributing factor to the nurse’s frustration, but this was not true for all nurses. Again, it seemed some personalities were better suited for the challenges of triage than others. SECURITY
Literature supports the presence of security to de-escalate problematic situations, but our research found that the mere presence of security was not necessarily helpful. Security guards had to have the ability and presence to perform their duties in acute situations. They must also have the personality traits to de-escalate situations rather than engaging in power battles with patients. Our participants stated that security guards also needed to possess a strong presence to be effective. At times, the security guards assigned to emergency departments were not up to par in the participants’ eyes, and nurses felt they were alone or without backup help. MANAGEMENT
Management seemed to be a neutral subtheme in this study. Most participants found them neither helpful nor unhelpful. Most participants who did not find management helpful stated that they usually did not ask for their help because of the perception that there was nothing that could be done anyway. Perhaps management should make a concerted effort to engage with staff and patients to ascertain ways that might make their presence known or make what they are able to offer staff better known. Some managers were perceived to be effective in de-escalating situations, but this was not a consistent finding. MANDATORY CLASSES
There are multiple types of behavior management courses available to emergency departments. Participants in this study named 3 separate courses, and all had similar experiences with them. The main observation by participants was that the courses have limited usefulness in a time-pressed environment such as
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the emergency department. If the staff had unlimited time to interact with patients, the likelihood of VWPV would decrease. This is not realistic in any ED situation. These classes were not designed for the acute, chaotic ED environment, in which time is severely limited. This leaves staff with a dearth of necessary tools in their de-escalation tool belts. Also, further research should critically evaluate classes that are offered that purport to give staff tools to deal with VWPV but, in actuality, may be contributing to staff frustration and feelings of inadequacy. Future development of behavior management courses should be focused on how best to implement tools under severe time pressures and how to avoid the escalation of problems between nurses and patients in the first place. Education of patients before coming to the emergency department, perhaps by their primary medical physicians, regarding standard wait times and procedures is recommended. There should be resources available in triage to explain the process and keep patients updated and perhaps even a dedicated resource nurse that has no patient assignment to watch for and intervene when a situation does begin to escalate. Identifying personality traits that can be helpful or harmful that can be modified might also be useful in these types of courses. Protective factors include an affinity for the pace and environment of the emergency department but more for the people with whom one works. We should focus on these protective factors, including fostering and nurturing peer relationships and communication. Perhaps sponsoring employee bonding events and even staff meals may continue to foster and build ED staff member relationships and offset feelings of OD. Mitigating the feelings of OD may contribute to happier, more fulfilled staff members and may reverse the negative cycle and ease the frustrations of ED RNs.
Limitations
There were a few limitations to this study. All participants were from the West Coast and may not be representative of all ED RNs. Many of the participants worked in busy trauma centers, which may also influence the generalizability to ED RNs who work in smaller hospitals without official trauma designation. Journaling and self-reflection were employed throughout the interviews; however, on some level, the perceptions and ideas of the researcher surely influenced the data analysis.
Implications of Findings to ED Nursing Practice
There are numerous implications of these findings to ED Nursing Practice, although—as with any grounded-theory
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study—more research is needed to develop the central tenets of this study. Hospital administrators, nursing educators, and formal nursing agencies should be aware of—and discuss—OD with new and seasoned nurses alike. Areas that are causative of OD should be mitigated when possible, and areas that are protective should be supported. At times, advocacy groups and formal position papers from regulatory and representative agencies place heavy focus on managerial support. This study demonstrates that managerial support is a neutral factor in OD and not as important as peer support, which was found to be a protective factor. Therefore, more attention should be placed on fostering positive and beneficial peer relationships such as staff lunches, extracurricular activities, placing peer-identified supportive staff members in triage together, and other ideas as suggested by staff members themselves. Emergency department RNs and educators should focus on re-evaluating current mandatory de-escalation or behavior management courses for efficacy. Continued input into these courses is necessary and perhaps even the development of new courses specifically designed for the challenges the ED RN encounters daily. More “just in time” tools should be available for the ED RN in the time-sensitive environment of the ED.
Conclusions
Although OD may seem disheartening, the authors would like to end on a more positive note. Study participants often discussed the positive and protective influence of “nice” patients, peers, and physician colleagues. Paula, with 23 years’ experience, said: "Having said that, of course, it’s the mean ones who make the most impression, but most people are normal human beings, and that’s the saving grace because if it really was every single person, you just couldn’t do the job. You are so grateful for these people. I tell patients that all the time. I say ‘thank you so much.’" Katie, with 11 years of ED experience: "It doesn’t even have to be exceptional, but just like I said, even a mere thank you, it really ties it all together. I really feel that nursing is my calling in life. When I have a day like that, a good day, quote, unquote— “a good day”—I feel complete. I feel blissful.” Agnes, with 13 years of ED experience: "Because as much as there are people who are not appreciative or rude, there are the people who are appreciative and are kind and sweet, you know. There are nice people. The good outweigh the bad. Because, you know, it wouldn’t be fair to the people who deserve your care or who are appreciative not to
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have you be there or have an attitude if you let all the bad stuff weigh you down. Yeah, the nice people keep me going." Verbal WPV does not hold true to the old childhood rhyme "Sticks and stones will break my bones, but words will never hurt me." Indeed, words hurt, and VWPV is considered a form of psychological abuse that has persistent negative effects. Certainly, more research is needed to validate this study's findings and continue to explore factors contributing to OD. More research is also needed to develop a course to address VWPV, PWPV, and useful de-escalation techniques in a time-limited environment. Subtle support changes, such as modifying the triage environment and encouraging staff relationships, may also decrease feelings of OD. These modifications and support may serve to break the negative cycle of ED RNs carrying over negative experiences from one patient to another and may help create a calmer atmosphere in a sea of ED chaos.
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