Violence against nurses in the triage area: An Italian qualitative study

ARTICLE IN PRESS International Emergency Nursing ■■ (2015) ■■–■■

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Violence against nurses in the triage area: An Italian qualitative study Nicola Ramacciati RN, MSN, MA (PolSci) (Head Nurse) *, Andrea Ceccagnoli RN, BSN, MA (Bio) (Registered Nurse), Beniamino Addey RN, BSN (Registered Nurse) Emergency Department, Perugia Hospital, Loc. S. Andrea delle Fratte, 06132 Perugia, Italy

A R T I C L E

I N F O

Article history: Received 2 December 2014 Received in revised form 11 February 2015 Accepted 16 February 2015 Keywords: Workplace violence Emergency medical services Triage Qualitative research Emotions Italy

A B S T R A C T

Aim: This qualitative study aims to investigate the feelings experienced by nurses following episodes of violence in the workplace. Background: Numerous studies show that healthcare professionals are increasingly finding themselves victims of violence; of all professionals, nurses in the Emergency Department and especially those performing triage are one of the staff categories which most frequently experience these episodes during their work. Introduction: In Italy, this phenomenon has been studied very little in comparison to other countries but has recently been gaining increasing attention. Few studies have investigated the feelings experienced by nurses following episodes of violence in the workplace. Methods: For this study a phenomenological approach was used. Assumptions and previous findings were set aside (bracketing). A purposive sample of 9 nurses coming from 7 different Emergency Department in the region of Tuscany, Italy was interviewed during a focus group meeting. The data analysis was carried out using the Colaizzi method. Results: Data analysis revealed 10 significant themes/responses. The quality of reporting was guaranteed by adopting the COREQ criteria. Discussion: Data analysis revealed that nurses feel that violent episodes are “inevitable” and that they feel they have grown accustomed to high levels of violence, that they suffer feelings of “inadequacy” but also that they are aware that they themselves can trigger conflict with patients, and again suffer the feeling of “being alone” in facing these problems and a sense of “being left on their own” by the institution and feeling “hurt”, “scared”, “angry” and have a sense that “it is not fair”. Last but not least, “the gender difference” appears to play an important role in the emotional response. Conclusions: To suffer episodes of violence has serious and severe “hidden costs” which are just as important as the direct, tangible costs. © 2015 Elsevier Ltd. All rights reserved.

1. Introduction Episodes of violence and aggression towards healthcare professionals are a growing phenomenon worldwide. According to the International Council of Nurses, healthcare professionals are more exposed to episodes of aggression than are prison guards and police officers (Taylor and Rew, 2010). For a long time many international organisations such as the International Labour Office, the International Council of Nurses, the World Health Organization and the Public Services International have issued guidelines

Author contributions: A.C. data collection/analysis, B.A. drafting of manuscript. Source of funding statement: This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. * Corresponding author. Emergency Department, Perugia Hospital, Loc. S. Andrea delle Fratte, 06132 Perugia, Italy. Tel.: +39 0755782488; fax: +39 0755782488. E-mail address: [email protected] (N. Ramacciati).

designed to tackle the problem of violence in healthcare settings (ILO/ICN/WHO/PSI, 2002). Of all healthcare professionals, triage nurses are most at risk (Pich et al., 2010); this trend also emerges quite clearly from studies conducted by the Institute for Emergency Nursing Research (IENR) which is a research institute under the auspices of the U.S. Emergency Nurses Association (ENA), which has published a statement on its own position as regards violence in the Emergency Department (ENA, 2014). 2. Background/literature Many studies published in the international literature have explored the issues of patient-related violence against nurses, with a particular focus on the ED setting. A preliminary research of the international literature on this topic can be conducted in CINAHL and PubMed databases using as search terms: “emergency”, “aggression”, “violence”, and “abuse”. Google Scholar provides a simple

http://dx.doi.org/10.1016/j.ienj.2015.02.004 1755-599X/© 2015 Elsevier Ltd. All rights reserved.

Please cite this article in press as: Nicola Ramacciati RN, MSN, MA(PolSci), Andrea Ceccagnoli RN, BSN, MA(Bio), Beniamino Addey RN, BSN, Violence against nurses in the triage area: An Italian qualitative study, International Emergency Nursing (2015), doi: 10.1016/j.ienj.2015.02.004

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Table 1 Literature review. Database

Query

Limiters

Items found

PubMed

((((aggression* OR abuse* OR violence OR assault* OR violent* OR workplace violence OR wpv)) AND ((emergency) OR triage))) AND (nurse*) ((abuse OR violence OR aggression* OR workplace n1 violence or wpv) AND (emergency or triage)) AND nurse*

Publication date <10 years

568

93

Publication date <10 years

637

123

CINAHL

Studies retrieved

procedure to make a broad search for scholarly and grey literature. We carried out this search in December 2010. This preliminary study allowed for the fine tuning of the research subject as well as providing useful elements for carrying out the ‘facet analysis’ necessary to identify the key terms to be used in the search strategy. To maximise the sensitivity of the research, the MeSH terms and the search terms were combined. To increase the specificity of the search in the CINAHL database, the proximity operators (Near) “N1” and “N2” were used in order to retrieve records with two terms in the same sentence or multiple words. In the PubMed database “search terms” in inverted double commas were used. The truncation operator (*) was used to simplify and maximise the search. Terms were combined using the Boolean operators OR and AND. A search was conducted in March 2011 and repeated in December 2012, November 2013 and November 2014 to capture any new published material. The Table 1 shows the results. Among the studies retrieved, out of which two were systematic reviews (Edward et al., 2014; Taylor and Rew, 2010), only a few have specifically focused on triage (Daniel et al., 2014; Morphet et al., 2014; Pich, 2009; Pich et al., 2011; Ramacciati et al., 2013a; Sands, 2007). The Italian Ministry of Health issued a specific recommendation for the prevention of acts of violence towards healthcare professionals in November 2007 and from 2006 onwards, these acts of violence were included as sentinel events within the Italian National Monitoring System of Errors in Healthcare (SIMES). The reports published to date show a growing trend in acts of violence against healthcare workers (Ministero della Salute, 2008, 2010, 2011, 2012) as also emerges from some Italian studies of violence towards healthcare professionals (Cerri et al., 2010; Magnavita and Heponiemi, 2012). In Italy a recent area of research focuses on the phenomenon of violence and aggression towards emergency department (ED) nurses (Becattini et al., 2007; Coviello et al., 2012; Desimone, 2011; Fabbri et al., 2012; Ramacciati and Ceccagnoli, 2012a; Zampieron et al., 2010). The main focus of research in this field to date has been concerned with quantifying the phenomenon, understanding the types of violent acts (verbal or physical) and the perpetrators (patients, their relatives or their friends), precipitants and risk factors, attempts on the part of healthcare providers to address the problem (zero tolerance, prevention, staff educational training schemes, architectural layout interventions) as can be seen from review studies on this subject (Anderson et al., 2010; Brunetti and Bambi, 2013; Ferns, 2005; Gillespie, 2008; Lau et al., 2004; Ramacciati and Ceccagnoli, 2011). These studies are generally analytical and descriptive, usually with a mixed qualitative/quantitative methodology and widespread use of questionnaires. Qualitative studies also tend to focus on the same themes (Angland et al., 2013; Catlette, 2005; Gillespie et al., 2010, 2013b; Luck et al., 2008; Pich et al., 2011, 2013) and the attention given to the experiences and feelings of the staff suffering aggression is sometimes only marginal as one of several aspects analysed according to research protocols (ILO/ICN/WHO/PSI,

2003a). It is for this reason that our work team wished to investigate the feelings experienced by Emergency Department nurses who have suffered aggression in the Triage area, in line with the aims which lie at the root of their own research work: all the causal factors of Workplace Violence can be grouped as seen by the nurses’ viewpoint into four fields: external, internal, environmental/contextual, and organisational. The complexity of the phenomenon and the strong interrelation between various factors suggest that the problem of violence in the ED could be effectively faced only with multiple strategies (Ramacciati et al., 2013a). In our ED from 2009 onwards, subsequent to the alert on three sentinel events of acts of violence towards operators, and in cooperation with our Clinical Risk Management Centre, an action plan structured on four distinct intervention levels was put in place, with the aim of facilitating communication/information with the public, redesigning the admissions procedure and modifying the triage operating spaces, acquiring greater staff communication competence, implementing an operations protocol for the management of risk in violent situations and monitoring violent events (Ramacciati et al., 2013b). But this did not seem sufficient. The department needed to know what thoughts, feelings and behaviours ED nurses experienced after a violent incident. The aim of this study is to give a clear picture of the feelings experienced by nurses working in the triage area following an episode of physical or verbal violence perpetrated by a user of the ED healthcare facilities and/or by those who accompany them, by means of a study with a qualitative approach. This method was chosen because it allows for the unfolding of full, rich, introspective descriptions which enables the phenomenon of violence to be explored and examined from an innovative perspective. There are many different definitions of workplace violence (WPV); for the purposes of this study we have adopted the definition used by the National Institute of Occupational Safety and Health (NIOSH) and we have given this definition to participants to ensure consistency in their understanding. NIOSH defines workplace violence “as violent acts (including physical assaults and threats of assaults) directed toward persons at work or on duty” (National Institute of Occupational Safety and Health, 2002, p. 1). The perpetrators of this violence are either patients or persons accompanying patients, whether relatives or friends. 3. Methods The method used for gathering data was a focus group for nurses who had experienced violence in the triage area. The group meeting was conducted according to the specific guidelines of the International Labour Office, International Council of Nurses, World Health Organization and Public Services International (see Appendix S1). Prior to the meeting, participants were asked for their consent for the use of their personal data for the purposes of research and a document attesting voluntary participation in the study was requested, full anonymity being guaranteed. The personal data included age, degree, job qualification, seniority, work in ED, address, and e-mail. An audio recording of the focus group meeting and a subsequent word for word transcription was necessary in order to ensure complete accuracy in the data gathering process; the abovementioned informed consent also referred to this recording. The data analysis was carried out using the Colaizzi method which entails: the recording of the participants’ descriptions of their experiences, extrapolation of significant statements, the grouping together of these into themes and, after a complete account of these descriptions has been written, a thorough examination of this account by the participants in order to have their confirmation of the correctness of the descriptions. In order to ensure the rigorously scientific nature of the study, the three elements required for confirmability in qualitative research were carefully observed: auditability and quality of reporting

Please cite this article in press as: Nicola Ramacciati RN, MSN, MA(PolSci), Andrea Ceccagnoli RN, BSN, MA(Bio), Beniamino Addey RN, BSN, Violence against nurses in the triage area: An Italian qualitative study, International Emergency Nursing (2015), doi: 10.1016/j.ienj.2015.02.004

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by adopting the COREQ – Consolidated Criteria for Reporting Qualitative Research (Tong et al., 2007), credibility by giving the participants the opportunity to read and if necessary correct their descriptions and the themes/issues which emerged from the data analysis and fittingness by using direct quotes from the participants in order to allow their experiences to illustrate the factors identified as representative of this phenomenon directly. 3.1. Research team The research team consists of the three authors, all clinical nurses in the Emergency Department (of which the first author is the coordinator) at a national level university hospital, all male, with experience of qualitative research gained by taking part in a qualitative study on pharmacovigilance. No member of the research team knew the study participants prior to the investigation (the three authors work in a different hospital from the hospitals where the participants work) and the participants received information on the researchers and were informed as to the reasons, premises and basic aims of the research project during the introductory phase of the meeting in Siena which took place on 18th January 2013. 3.2. Research design The theoretical basis of this study is a concept developed by the authors in which violence is seen as a multi-factorial phenomenon which can be deconstructed, from the nurses point of view, into four separate component areas: external, internal, contextual, organisational. The complexity and the interconnection between the different factors necessarily calls for a “multidimensional” analysis of the operational context and a full range of specific responses (Ramacciati et al., 2014). Nevertheless all knowledge, ideas and beliefs previously held on the research subject were put aside in adherence to the concept of bracketing in order to minimise personal biases (Gearing, 2004). The criteria for the selection of participants was purposive: a person who was not part of the research team contacted the potential candidates (nurses with experience of triage who had been involved in episodes of violence) by phone and email. Nine participants took part in the study coming from 6 Emergency departments in Tuscany (Florence, Lucca, Siena, Nottola, Valdarno, Campostaggia). No-one refused to take part in the study. The meeting with the focus group participants took place in a meeting room belonging to the 7th AUSL (Medical District) of Siena with the sole presence of the researchers. The characteristics of the sample are briefly described in Table 2. In order to encourage the discussion, a short questionnaire was given to the participants. Their responses are given in Table 3. The

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Table 3 Responses to the introductory questionnaire.

Have you heard about the phenomenon of violence in the triage area? Yes No Have you had any specific instruction on the issue? Yes No How did you react? – It depended on the situation – I called the police – I tried to keep calm, be professional about it, mediate – No reply

n

%

8 1

89% 11%

3 6

33% 67%

1 3 3 2

11% 33% 33% 23%

focus group meeting lasted 100 minutes; an audio recording was made and the second author took field notes while participants were speaking. 3.3. Data analysis Everything the participants said was recorded and the recording was listened to several times and transcribed by two of the authors (A.C., B.A.). An examination of the data and an initial labelling was carried out independently by the three researchers and the results of these analyses were compared and the themes and issues which emerged were identified. All the themes identified derived from the data analysis. The interpretation of the experiences and of the characteristic factors in these experiences emerging from the descriptions gathered during the discussion were shared with all the participants and verified by 7 of them (2 did not give any feedback). 3.4. Ethical issues Ethical approval from the Ethics Health Committee of Umbria was only informally sought, because ethical approval is not normally required for research involving NHS or social care staff recruited as research participants because of their professional role. However the utmost respect for the ethical aspects was guaranteed: all the research participants were informed by a prior letter of invitation as to the aims of the research; an informed consent form was signed by each participant and this consent form contained all the information on the purposes for which the data were requested and on the processing procedures, according to the Italian personal data protection Code. Maximum privacy and anonymity was guaranteed (the participants were codified and the transcriptions were not identifiable); participation in the study was voluntary and there was no conflict of roles between the participants and the researchers. 4. Results

Table 2 Characteristics of the sample. Characteristics Sex Female Male Age Years worked Years of work in the emergency department Qualifications Regional diploma Degree (three years) Degree (magisterial) Specialisations Master in nursing coordination Master in Emergency nursing None

n

Average

SD

44 years 18 years 11 years

±6 ±7 ±7

6 3

7 2 0 4 2 3

From an analysis of the statements made during the meeting of the focus group, 10 themes or issues emerged. The results are described in the order in which they emerged since the participants considered them all to be equally relevant. 4.1. Feeling vulnerable One of the most commonly felt issues was that of feeling “vulnerable and unsupported”. This experience was clearly and specifically mentioned by participant 4 who said “They just leave you there in the thick of it. Yes, I often feel that I am between the devil and the deep, blue sea” (In Italian, literally:“between the hammer and the anvil”). Or, as participant 8 said, “You are left with a bad feeling, probably because you are not expecting it. And also

Please cite this article in press as: Nicola Ramacciati RN, MSN, MA(PolSci), Andrea Ceccagnoli RN, BSN, MA(Bio), Beniamino Addey RN, BSN, Violence against nurses in the triage area: An Italian qualitative study, International Emergency Nursing (2015), doi: 10.1016/j.ienj.2015.02.004

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because you feel you cannot defend yourself.” This concept was mentioned by participant 9, “It’s psychological violence when you feel vulnerable and there’s no-one to defend you”. Participant 7 stated, “The law prevents us from reacting, because even if you are just trying to defend yourself, you are suddenly in the wrong, so we just have to stand there and take it.” 4.2. Feeling alone and unsupported by management Feeling vulnerable and unsupported feeds into another sensation described by the participants: “feeling alone and abandoned”. Participant 3 said, “there’s nobody to talk to”; participant 4, referring to the hospital management staff, added, “they’re not listening to the people who are there working every day and pointing things out. . .” and participant 8 is even more explicit and said, remembering an episode of violence, “nobody cared at all, not even the head nurse. You feel abandoned”. Not being given consideration, not being listened to by coordinators and management appears to make people angry. On this subject, participant 8 said, “several months have gone by (after an audit) and we have made suggestions for improvements, brought them to the attention of the company, but the machinery works so very, very slowly, and that makes people angry” and added, “If a client damages something belonging to the hospital, like a door, the hospital takes that person to law. If the client hits me and I want to take him to law over this, I have to do it by myself. And this is one of those things that leaves a bitter taste: it means that I am not as important as that door.” She continued, “One of our demands, for example, apart from psychological support, is for an examination of the possibility for the legal department to offer the staff advice. As things stand at the moment, this is not forthcoming.” Whereas there seems to be a lack of support from the upper levels of the hospital hierarchy, there does seem to be support from colleagues. Participant 5 said, “Nowadays, as soon as we hear raised voices from the Triage area, somebody automatically leaves the surgery and goes to give support to the colleague out there”. But support does sometimes come from above, as participant 1 said, “in my case, my coordinator openly defended me, in front of me, and I felt really supported by that, it had a healing effect at the time.” 4.3. Feelings of inadequacy and guilt Triage nurses who had been exposed to violence reported feelings of deep hurt. Participant 1 said, “I think you feel guilty because this upsetting episode has happened to you.” Likewise participant 3 said, “I felt guilty because emotionally I hadn’t been able to deal with that person.” He continues, “I still feel inadequate sometimes, as if I were at fault.” Participant 8 confirms, “Yes, you think maybe someone else would have reacted differently and nothing would have happened.” 4.4. Injustice When one has suffered violence, it can give rise to very different feelings: inner guilt as mentioned above or, projected onto the outside, this can be perceived as an injustice. In this vein, participant 1 said, “there are a couple of incidents which I remember most because they made a deep impression on me and especially the first one, it took me about six months to get over it. It felt like something personal, an injustice.” It can be hard to make sense of this: “the attacks which hurt me most were not in Triage but inside ED surgery and they hurt me a lot, because it was the patient’s relative (. . .) how could you do that? Tell me why. I did everything I could, even more than I was supposed to, and you turned violent. Why?” (Participant 5). Participant 6 said, in a similar vein, “What always upsets me is the feeling that I am not against anyone, I’m

not there because I’ve got it in for the person who comes in.” This injustice, as participant 3 said, is perceived as “violence against you as a person, as a citizen and as a professional.” 4.5. Long lasting effects Violence also produces much deeper emotional pain, perceived and described as “wounds”. Participant 1 said, “I felt wounded” and participant 8, speaking of a colleague who suffered violence, said “she felt far more in danger, far more wounded.” These are deep wounds which may take a long time to heal. “There are a couple of incidents which I remember most because they made a deep impression on me and especially the first one, it took me about six months to get over it” (Participant 1). These wounds leave traces which never disappear: participant 3 said, “these things, of course, they leave a mark on you”. 4.6. Fear In the end, one of the psychological effects of physical or verbal violence is the fear of recurrence. Participant 7 states, “I was scared, scared, scared. Of course if someone shouts at me in the Triage area, it’s irritating and upsetting but being really scared is another thing altogether.” Participant 8, referring to a colleague who was attacked, said, “She said the worst thing about it is ”. 4.7. Inevitability Some participants reported having the feeling that the violence they experienced was “inevitable”. Participant 1 said, “maybe I could have suffered less over this but it’s part of the game (. . .) in the Triage area it really seems to be the norm, it seems like an inevitable part of the situation, as if we just can’t avoid it, and I’m constantly aware of the nurses’ uneasiness. Every day something happens where somebody says to me so that’s it, it has become. . .well, part of the daily game, an everyday occurrence.” Participant 5 said, “it’s become so much a part of things, so expected, that you take it as an everyday experience, even though it always hurts.” Participant 7 said, “Verbal abuse has become an everyday thing, we hardly notice it any more, I hardly consider verbal abuse as violence by now. I call it violence if someone comes to blows like they did in our ED, pulls a knife, that’s violence. Verbal abuse, I’m used to it, I regard it as an everyday experience.” The routine exposure to threats and violence which the personnel of ED experience ends up giving them a feeling of familiarity with the phenomenon, as we see from participant 7 who said, “Well, in my twenty-odd years of experience, verbal abuse, I hardly regard it as violence, by now it’s completely routine” and from the successive statement from participant 8: “I feel a bit sorry when you said before that all the violence was verbal, physical violence was only being pushed, nothing much. No, I feel I have a right not to be pushed when I am working but you do feel like saying it’s nothing much because you’re right, we take it for granted, I take it for granted and I am the newest member of staff.” 4.8. Excuse Violence as the norm even elicits a certain amount of justification, as participant 2 said, “there are pathological situations, like the old lady who gets mad and kicks: how can you call that violence? That’s more like psychiatric cases or drunks: it’s not deliberate violence, it’s part of the person’s illness” or as participant 8 said, with reference to an episode of violence, “he didn’t even seem to be a person with psychiatric problems”.

Please cite this article in press as: Nicola Ramacciati RN, MSN, MA(PolSci), Andrea Ceccagnoli RN, BSN, MA(Bio), Beniamino Addey RN, BSN, Violence against nurses in the triage area: An Italian qualitative study, International Emergency Nursing (2015), doi: 10.1016/j.ienj.2015.02.004

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4.9. Gender difference One interesting aspect which emerged during the focus group came from participant 8 who said, “there’s a basic difference between male and female staff, in the sense that when it’s a man who’s attacked, you can all tell me if you agree or not, he feels less hurt, probably because just trying to defend himself helps him not to feel so bad; maybe he’s aware that he won’t get too badly hurt because he can stand up for himself, or the fact that he would be able to assert himself by raising his voice or shouting makes him feel better, but when it’s a woman of my size who has been kicked, she perceives things as much worse, she felt the danger more, she was more hurt and more frightened, felt more alone.” This point is developed by participant 9: “we often try to generalise, it’s a cultural thing, but it is different with a male or a female, because we are used to fighting from when we are little in a different way from women and this has an effect” and by participant 4, “sometimes I am an easier target than my male colleagues and sometimes I am a more difficult target. It depends on the person who’s being violent. The fact is that in terms of my physical presence and personality and the way I behave, I tend not to attack, either verbally or physically, I tend rather to step back, make myself small, and try to keep calm. Sometimes this allows me to avoid being hit, but sometimes I get an insult thrown at me because of how I behave. If there were a male colleague instead of me at that point, someone big and tall, probably the situation wouldn’t arise, or else who knows what would happen. . .”. 4.10. Self awareness The last factor to emerge is self-awareness, an awareness of being part of the problem. Thus participant 9 said, “this thing (violence) can be triggered by our behaviour too.” Participant 7 said, “Sometimes we are at fault when we have episodes of violence from people who are neither psychiatric cases nor alcoholics, sometimes we are the ones at fault.” Participant 1 said, “There are people who have a brusque way of treating people and you can see that angry reply or the violence coming.” Participant 6 said, “A decisive reply, even if it is a bit brusque, is the kind of reply which is reassuring, even if it seems ‘rude’. But sometimes a rude reply deserves – I won’t say violence – but the violence is understandable.” 5. Discussion Many of the themes that have emerged from our focus group are consistent with and present in the international literature on this subject. Violence as an inevitable experience in an Emergency Department nurses’ everyday work is described by Jones and Lyneham (2000) as “part of the job for nurses”, which produces a sense of familiarity, or, as Erickson and Williams-Evans (2000) call it, a “habituation or normalization of violence in the workplace”. As recently described by Jacqueline Pich and colleagues, violence in the ED is also perceived by Italian nurses to occur frequently and to such an extent that nurses have become resigned to violence, expecting it and accepting it as inevitable (Pich et al., 2013). This is so much the case that in cases of pathologies resulting from alcohol abuse, psychotropic drugs, trauma or extreme old age and dementia, nurses tend to justify (Whittington and Winstanley, 2008) and play down violent episodes (Harulow, 2000). And yet the consequences and the effects which the “wounds” have on the victims, as we see from the narratives of many participants and as shown by Fernandes et al. (1999), often last for many months. Geberich et al. (2004) found that the effects can last for between 6 months and one year especially since structured debriefing and support (attention from the hospital employer) is lacking and only informal help is available (support from colleagues). Both of these aspects,

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found in our research, are present in the phenomenological study of Wanda Christie on the experience of ED nurses after patientperpetrated workplace violence, where the administrative support was perceived to be low, whereas perceptions of peer support were high (Christie, 2014). However this support does not seem sufficient to limit the loss of self-esteem cited by the participants and described by Hodge and Marshall (2007). Feelings such as anger, fear, sadness, helplessness, desire for revenge, lead nurses to distance themselves emotionally from the environment and from patients. These feelings may be accompanied by anxiety, burnout, depression, and acute and post-traumatic stress disorders, as consequences that can arise after an incident of workplace violence (Alexy and Hutchins, 2006). The awareness that some nurses may be more vulnerable than others to violent episodes was described by Winstanley and Whittington (2004). Hegney et al. consider that a direct correlation exists between the risk of violence and years of service, in the sense that nurses with less experience have a higher probability of becoming victims of violence (Hegney et al., 2003), whereas in the work by Lau et al. (2004), the gender difference emerges as mentioned by our participants, so that female nurses are more vulnerable to violence. Our focus group highlighted the possibility that sometimes female nurses may be more vulnerable to violence and sometimes it would appear that the female staff are seen as less challenging and therefore less of a trigger for violent acts. The focus group produced an important point that it may also be the case that male and female staff behave differently in the face of a threat of violence. In developing possible training for ED nurses on the subject of self-awareness and specific behaviour in situations where violence may arise, this gender difference might be usefully considered. This difference, probably culturally mediated, seems to play an important role in how the male and female nurses take on specific attitude in the face of violent patients/relatives. The cultural aspects have to be considered carefully as witnessed by important studies in this field (Lau et al., 2012; Wolf et al., 2014). Another important factor is the awareness, expressed by participants, that violent behaviour can be triggered by an attitude of the nurse, in the same way as other staff attitudes may avoid, prevent and reduce violence (Luck et al., 2009). 6. Conclusion The issues/themes and significant descriptions presented in this study reflect similar findings relevant to hospital staff experience of violence found in other research of this kind. The limits of this study are the small sample size and the restricted geographical area from which participants were drawn (Central Italy) with possible consequences for the general validity of the results. However, this qualitative study has strengthened our conviction that violence in the Emergency Department should continue to be monitored because the real risk of violence may differ from staff perception, as demonstrated by Blando et al. (2013). Specific actions will be undertaken, such as the awareness campaign among the personnel assigned to triage and reporting by triage staff of all events perceived as physical violence, threatening behaviour or verbal abuse occurring in the workplace. This reporting system is crucial not only for monitoring purposes but also for the immediate implementation of the necessary corrective actions. The importance of early debriefing following critical incidents is discussed by Healy and Tyrrell (2013) as well as the use of current recommended treatments with cognitive behavioural therapy (Bonner and McLaughlin, 2007). Intervention strategies provided for the victims of aggression such as personal reflection, participation in a defusing intervention, stress inoculation training, and professional counselling can be a useful approach in counteracting acute and post-traumatic stress disorders (Gillespie et al., 2013a). Job motivation, participatory leadership

Please cite this article in press as: Nicola Ramacciati RN, MSN, MA(PolSci), Andrea Ceccagnoli RN, BSN, MA(Bio), Beniamino Addey RN, BSN, Violence against nurses in the triage area: An Italian qualitative study, International Emergency Nursing (2015), doi: 10.1016/j.ienj.2015.02.004

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and best working conditions are factors which can prevent violence and mitigate its effects (Zampieron et al., 2010). However, although in the literature review of interventions designed to reduce violence against ED nurses there is no strong evidence for their efficacy (Anderson et al., 2010), the development of new qualitative studies on the experience of Emergency Department nursing staff who are victims of violence represents an important research area on Workplace Violence (ILO/ICN/WHO/PSI, 2003b) and a crucial tool in the effort to effectively (Richards, 2003) reduce the direct and indirect “cost” of violence (Ramacciati and Ceccagnoli, 2012b; Speroni et al., 2014). Acknowledgements The authors thank Giovanni Becattini, Nurse Manager of AUSL 7 of Siena (Italy), for his kind and productive cooperation and they especially thank the nurses who participated in the focus group. Appendix: Supplementary material Supplementary data to this article can be found online at doi:10.1016/j.ienj.2015.02.004. References Alexy, E.M., Hutchins, J.A., 2006. Workplace violence: a primer for critical care nurses. Critical Care Nursing Clinics of North America. 18 (3), 305–312. Anderson, L., FitzGerald, M., Luck, L., 2010. An integrative literature review of interventions to reduce violence against emergency department nurses. Journal of Clinical Nursing. 19 (17–18), 2520–2530. Angland, S., Dowling, M., Casey, D., 2013. Nurses’ perceptions of the factors which cause violence and aggression in the emergency department: a qualitative study. International Emergency Nursing. 22 (3), 134–139. Becattini, G., Bambi, S., Palazzi, F., Lumini, E., 2007. Il fenomeno delle aggressioni agli operatori di Pronto Soccorso: la prospettiva italiana, in: Atti XXVI Congresso Nazionale. Aniarti, Firenze, pp. 535–541. Blando, J.D., O’hagan, E., Casteel, C., Nocera, M., Peek-Asa, C., 2013. Impact of hospital security programmes and workplace aggression on nurse perceptions of safety. Journal of Nursing Management. 21 (3), 491–498. Bonner, G., McLaughlin, S., 2007. The psychological impact of aggression on nursing staff. British Journal of Nursing. 16 (13), 810–814. Brunetti, L., Bambi, S., 2013. Le aggressioni nei confronti degli infermieri dei dipartimenti di emergenza: revisione della letteratura internazionale. Professioni Infermieristiche. 66 (2), 1–8. Catlette, M., 2005. A descriptive study of the perceptions of workplace violence and safety strategies of nurses working in Level-1 trauma centers. Journal of Emergency Nursing. 31, 519–525. Cerri, R., Caserta, M., Grosso, M., 2010. Le aggressioni subite dagli operatori sanitari: indagine in un ospedale italiano. Assistenza Infermieristica E Ricerca. 29 (1), 5–10. Christie, W. (2014) The lived experience: how emergency department nurses resolve emotional pain after patient perpetrated workplace violence (Doctoral dissertation). University of Arkansas for Medical Sciences. Coviello, D., Musolesi, S., Bartolomei, M., Monesi, A., 2012. Exploratory survey on the perception of violence in the Emergency Departments. Scenario. 29 (2), 27S. Daniel, C., Gerdtz, M., Elsom, S., Knott, J., Prematunga, R., Virtue, E., 2014. Feasibility and need for violence risk screening at triage: an exploration of clinical processes and public perceptions in one Australian emergency department. Emergency Medicine Journal. doi:10.1136/emermed-2013-202979; emermed-2013–202979 [pii]. Desimone, L., 2011. La violenza verso gli operatori del Pronto soccorso. L’Infermiere. 48 (4), 33–36. Edward, K.L., Ousey, K., Warelow, P., Lui, S., 2014. Nursing and aggression in the workplace: a systematic review. British Journal of Nursing. 23 (12), 653–654, 656–659. ENA, 2014. Position Statement: Violence in the Emergency Care Setting. Emergency Nurses Association, Des Plaines, IL. http://www.ena.org/SiteCollectionDocuments/ Position%20Statements/ViolenceintheEmergencyCareSetting.pdf accessed 20/1/2015. Erickson, L., Williams-Evans, S.A., 2000. Attitudes of emergency nurses regarding patient assaults. Journal of Emergency Nursing. 26 (3), 210–215. Fabbri, P., Gattafoni, L., Morigi, M., 2012. Un problema emergente: le aggressioni nei servizi sanitari. L’Infermiere. 49 (4), 12–14. Fernandes, C.M., Bouthillette, F., Raboud, J.M., Bullock, L., Moore, C.F., Christenson, J.M., et al., 1999. Violence in ED: a survey of health care workers. Canadian Medical Association Journal. 131 (10), 1245–1248. Ferns, T., 2005. Violence in the accident and emergency department – an international perspective. Accident and Emergency Nursing. 13 (3), 180–185.

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Please cite this article in press as: Nicola Ramacciati RN, MSN, MA(PolSci), Andrea Ceccagnoli RN, BSN, MA(Bio), Beniamino Addey RN, BSN, Violence against nurses in the triage area: An Italian qualitative study, International Emergency Nursing (2015), doi: 10.1016/j.ienj.2015.02.004

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Please cite this article in press as: Nicola Ramacciati RN, MSN, MA(PolSci), Andrea Ceccagnoli RN, BSN, MA(Bio), Beniamino Addey RN, BSN, Violence against nurses in the triage area: An Italian qualitative study, International Emergency Nursing (2015), doi: 10.1016/j.ienj.2015.02.004