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Workplace Violence Against Emergency Nurses in Taiwan: A Cross-Sectional Study
RESEARCH
WORKPLACE VIOLENCE AGAINST EMERGENCY NURSES IN TAIWAN: A CROSS-SECTIONAL STUDY Authors: Hui-Ling Lee, RN, MSN, Chin-Yen Han, RN, PhD, Bernice Redley, RN, PhD, Chun-Chih Lin, RN, PhD, Mei-Ying Lee, RN, MSN, and Wen Chang, RN, PhD, Taoyuan City, Taiwan, and Victoria, Australia
Methods: In this multicenter, descriptive, cross-sectional Contribution to Emergency Nursing Practice
The current literature on workplace violence against emergency nurses indicates that the phenomenon is common worldwide. This article contributes the main finding that Taiwanese emergency nurses are not satisfied with the current prevention measures implemented in emergency departments. The key implication for emergency nursing practice found in this article is that the measures should be reformed in order to reduce the impact of workplace violence against emergency nurses.
Abstract Introduction: Workplace violence against emergency nurses is common worldwide. This study aimed to gain a more thorough overview of the point prevalence of workplace violence against emergency nurses and the preventive measures used in emergency departments in Taiwan.
Introduction
Workplace violence (WPV) is verbal and physical violence against a person or persons on duty or at work, and incidents of WPV often occur in hospitals.1 Among health-care
Hui-Ling Lee is a Lecturer, Department of Nursing, Chang Gung University of Science and Technology, Taoyuan City, Taiwan. Chin-Yen Han is an Associate Professor, Department of Nursing, Chang Gung University of Science and Technology; and an Associate Research Fellow (joint appointment) Department of Nursing, Chang Gung Memorial Hospital at Linkou, Taoyuan City, Taiwan. Bernice Redley is an Associate Professor, Centre for Quality and Patient Safety Research — Monash Health Partnership, School of Nursing and Midwifery, Deakin University, Victoria, Australia. Chun-Chih Lin is an Associate Professor, Department of Nursing, Chang Gung University of Science and Technology; and an Associate Research Fellow (joint appointment) Department of Nursing, Chang Gung Memorial Hospital at Linkou, Taoyuan City, Taiwan.
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study, the questionnaire, Violence Against Nurses Working in Emergency Departments, was used to collect data from 407 nurses working at 5 emergency departments in Taiwan from May to October 2015. Results: The results revealed that 378 emergency nurses (92.9%) experienced workplace violence over the last 2 years. The average visual analog scale score (1-10) of security effectiveness in preventing workplace violence was 5.0 (SD ¼ 1.97). The average visual analog scale score of perceived safety level in terms of workplace violence was 4.38 (SD ¼ 2.06). The average visual analog scale score of meeting nurses’ needs was 5.72 (SD ¼ 2.23). Discussion: This questionnaire survey revealed that the cur-
rent preventive measures for workplace violence against emergency nurses in Taiwan were not effective. The relevant measures should be improved, thereby reducing the prevalence and severity of workplace violence against emergency nurses. Key words: Emergency department; Nurses; Questionnaire;
Workplace violence
personnel, nurses in particular are at high risk of WPV,2,3 and the prevalence rate of WPV-related injury in nurses is 1.7 times higher than in other health-care workers.1 WPV against nurses occurs more frequently in emergency departments than in other hospital departments in
Mei-Ying Lee is the Director, Department of Nursing, Saint Paul’s Hospital, Taoyuan City, Taiwan. Wen Chang is an Assistant Professor, Chang Gung University of Science and Technology, Taoyuan City, Taiwan. For correspondence, write: Wen Chang, RN, PhD, Chang Gung University of Science and Technology, 261 Wenhua 1st Road, Guishan Dist, Taoyuan City, Taiwan 33303; E-mail: [email protected]. J Emerg Nurs 2019;-:1-6. 0099-1767 Copyright Ó 2019 Emergency Nurses Association. Published by Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.jen.2019.09.004
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China, Italy, Taiwan, and the United States,2-6 suggesting a common phenomenon around the world. Emergency nurses can encounter WPV as often as daily,5 and 45% of abused emergency nurses suffered from depression, resulting in reduced enthusiasm and work satisfaction,7 quitting nursing,5 diminishing patient safety,8 and dampened quality of health care.8 Hence, the Emergency Nurses Association advocates a zero-tolerance policy for WPV.4 WPV against emergency nurses in Taiwan has been rarely explored. To provide a more thorough overview of the point prevalence of WPV against emergency nurses and the preventive measures implemented in emergency departments in Taiwan, the present multicenter crosssectional study was conducted.
Methods DESIGN
The present cross-sectional questionnaire survey included emergency nurses recruited from 2 public and 3 private hospitals in Taiwan and was conducted from May to October 2015. The study protocol was approved by the institutional review boards of all participating hospitals, and written informed consent was obtained from all participants. QUESTIONNAIRE
The self-reporting questionnaire Violence Against Nurses Working in Emergency Departments, developed by Gacki-Smith et al,9 was used to collect data. Face validity was assessed by 15 experts, and the instrument was revised based on their recommendations. The original English questionnaire was translated into Mandarin with the permission of Gacki-Smith, and back-translated into English. Five experts assessed the content validity of the questions using the content validity index (CVI) to determine applicability, clarity of expression, and content coverage. The Mandarin questionnaire was then revised as suggested by experts, and CVI values were calculated on the second assessment. Each question had a CVI value >0.8. The Cronbach’s alpha for the Likert scale questions (2, 6-8, 13, and 15) was 0.96, indicating good reliability and validity. Demographic characteristics were also collected. STATISTICAL ANALYSIS
The results of descriptive statistics were presented as frequency, percentage, mean, and SD. The required sample size was estimated using G*Power 3.1 software. Group dif-
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ferences were tested using t test and x2 analyses and analyzed by Fisher's exact test, as >20% of the expected subjects was less than 5 in the x2 test, a was set at 0.05 and power was 0.93-0.95. Statistical analyses were performed by using Statistical Package for Social Science (SPSS) version 19.0 (IBM Corp, Armonk, NY).
Results DEMOGRAPHIC PANTS
CHARACTERISTICS
OF
PARTICI-
A total of 440 questionnaires were distributed to emergency nurses at 5 hospitals, and 407 completed questionnaires were subject to final analysis. The mean age of the nurses was 31.50 (SD ¼ 7.0) years. Most participants were female (93.6%) and had a bachelor’s degree (73.9%). The mean nursing experience was 9.25 (SD ¼ 7.44) years, and the mean ED experience was 7.40 (SD ¼ 6.49) years. PREVALENCE OF WPV AGAINST EMERGENCY NURSES
The majority of emergency nurses experienced WPV (92.9%) within the past 2 years, and most WPV incidents occurred within the previous 6 months (41.6%). WPV incidents occurred most frequently during the afternoon shift (54.2%) and in the treatment area (61.2%). Most emergency nurses (58.5%) believed that WPV incidents had increased since last year. NURSES’ PERCEPTIONS ABOUT PREVENTIVE MEASURES IMPLEMENTED IN EMERGENCY DEPARTMENTS
The security effectiveness in preventing WPV was ranked using a visual analog scale (VAS) of 1-10 (1 ¼ not at all effective, 10 ¼ extremely effective), and the average VAS score was 5.0 (SD ¼ 1.97; Table 1). Participants ranked their safety levels in terms of preventing WPV by VAS 110 (1 ¼ unsafe, 10 ¼ extremely safe), and the average VAS score was 4.38 (SD ¼ 2.06). Only 69.8% of emergency nurses had received training for WPV prevention, and 46% of emergency nurses reported that the WPV prevention training was mandatory in their hospital. The average VAS score was 5.72 (SD ¼ 2.23) for the extent to which the WPV prevention training met the needs of emergency nurses (VAS, 1 ¼ did not meet needs, 10 ¼ fully met needs). In addition, 54.7% of participants discussed nurse safety in ED staff meetings daily or weekly (Table 1).
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TABLE 1
TABLE 2
Perception of registered nurses of the preventive measures against WPV implemented in emergency departments
Administrative issues surrounding preventive measures against WPV in emergency departments
Items
Is this a zero-tolerance policy, that is, a policy mandating that any and all violent incidents directed at an RN in the emergency department are to be reported? Yes No Missing value Do you believe that your hospital administration is committed to eliminating WPV against RNs in the emergency department? Yes No Missing value Barriers to reporting WPV* None/no barriers May affect customer service scores/reports Fear of retaliation from nursing staff Fear of retaliation from hospital administration Inconvenient/don’t want to deal with it Perceived as a sign of incompetence and weakness Violence comes with the job Ambiguous reporting policies No one reports these incidents Staff did not sustain any physical injury
Total, n [ 407
Does your hospital have a security system? Yes No The effectiveness of security in preventing violence against RNs in emergency departments (VAS 1-10) The overall level of safety from workplace violence in emergency department (VAS 1-10) Is your hospital training for the prevention/diffusion of violence in the emergency department mandatory? Yes No Missing value Where have you attended training/ course(s) for handling WPV prevention in the emergency department? Current hospital or other location Never attended How often is RN safety discussed in your ED staff meetings? Daily Weekly Monthly Quarterly Semi-Annually Annually Never Missing value
405 (99.5%) 2 (0.5%) 5.0 6 1.97
4.38 6 2.06
186 (46%) 218 (64%) 3
284 (69.8%) 123 (30.2%)
86 (22.6%) 129 (32.1%) 57 (14.2%) 63 (15.7%) 53 (13.2%) 8 (2%) 6 (1.4%) 5
Values were expressed as n (%) or mean 6 standard deviation. RN, registered nurse; WPV, workplace violence; VAS, visual analog scale.
In the present study, 226 (54.8%) participants claimed no hospital policy for reporting WPV against emergency nurses (Table 2). Only 39 (9.8%) emergency nurses recognized no barriers to reporting WPV. The commitment of the hospital administration to eliminating WPV against
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Total, n [ 407
Items
179 (44.2%) 226 (54.8%) 2
164 (41.1%) 235 (58.9%) 8 39 (9.8%) 90 (23.5%) 41 (10.3%) 110 (27.6%) 144 (36%) 107 (26.8%) 143 (35.8%) 90 (22.5%) 84 (21%) 292 (73%)
RN, registered nurse; WPV, workplace violence. * This is a multiple selection question.
emergency nurses was questioned by 235 (58.9%) participants (Table 2). PRECIPITATING FACTORS FOR WPV AGAINST NURSES IN EMERGENCY DEPARTMENTS
Precipitating factors for WPV against emergency nurses were classified as environmental, patient-related, caregiver-patient relationshiprelated, and administrative (Supplementary Table 1). The 3 most common
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precipitating factors were “patients/visitors under the influence of alcohol” (88.7%), “holding/boarding patients” (85.5%), and “prolonged wait times” (72.4%). Because of WPV, 79.6% of participants considered working in a department other than the emergency department, and 92.7% considered leaving the emergency nursing profession (Supplementary Table 2). DEMOGRAPHICS, ENVIRONMENTAL SAFETY, AND ED POLICY BY TYPE OF WPV
Among emergency nurses who experienced WPV, 371 (91.2%) suffered from verbal abuse and 306 (75.2%) suffered from physical abuse (Supplementary Table 3). Age, nursing experience, and ED experience were significantly greater in participants who were verbally abused than in those who were not (all P < 0.05). In contrast, no significant differences in age, nursing experience, or ED experience were observed between participants who encountered physical violence and those who did not. Significant differences were observed in the presence of a zero-tolerance policy between participants experiencing verbal abuse and those who did not (Fisher's exact test, P ¼ 0.01) and between participants experiencing physical abuse and those not (x2 ¼ 9.86, P ¼ 0.002). In addition, significant differences in being instructed to report WPV, the commitment of hospital administration, and the discussion of safety issues were also observed between those experiencing verbal abuse and those not, and between participants experiencing physical abuse and those who had not (all P < 0.05, Supplementary Table 3). Discussion
The present study found that 92.9% of 407 Taiwanese emergency nurses reported suffering from WPV within the last 2 years. Several cross-sectional studies also indicated high prevalence rates of WPV against emergency nurses worldwide.9-11 A cross-sectional study of 3,465 nurses who are members of the Emergency Nurses Association revealed that 70% of emergency nurses experienced WPV over the past 3 years.9 The Australian study Violence in Emergency Nursing and Triage (VENT) of 537 emergency nurses indicated that 87% of participants experienced WPV within the last 6 months.10 In addition, a survey of 227 Jordanian emergency nurses found that 75% experienced WPV.11 Despite the 24-hour security in emergency departments, our study participants did not feel safe in the emergency department, as evidenced by the average score of 4.38 for emergency nurses’ perceived safety level. By law, all
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emergency departments in Taiwan are required to be protected by security guards 24 hours a day, so “no security system” reported by 2 emergency nurses was due probably to a lack of awareness of the resource (Table 1). In the US, emergency nurses reported extreme dissatisfaction with workplace safety.9 The present study suggested that emergency nurses do not feel safe at work, which may in part be due to the lack of a hospital policy for reporting WPV and the perceived barriers to reporting WPV. An efficient reporting system is a critical component of a prevention strategy against WPV,12 and multiple forms of communication have been suggested recently to diminish the barriers to reporting WPV.13 Two studies of Taiwanese emergency nurses indicated that WPV not only caused emotional and physical injuries but also might drive nurses away from emergency nursing.7,14 Frequent exposure to WPV, either experiencing it or witnessing violent incidents, diminished the enthusiasm of emergency nurses.7,14 A Korean crosssectional study reported that 61.0% of abused emergency nurses considered leaving the nursing profession.15 In our study, 92.7% of participants also considered leaving the emergency nursing profession because of WPV. Peer support is essential to help abused emergency nurses strengthen their resilience to WPV in Taiwan,16 suggesting the potential role of ED staff meetings in reducing the negative impact of WPV. Two studies further suggested that hospital managers should encourage peer support and educate emergency nurses to examine their feelings, thereby improving their emotional health.17,18 Finally, a situational simulation training course is an effective tool for enhancing the coping skills of emergency nurses and thus a way to minimize the negative effects of WPV in Taiwan.19 This study found that alcohol, holding/boarding patients, and prolonged wait times were the 3 most common precipitating factors for WPV against emergency nurses. The Australian VENT study also stressed the stimulating role of alcohol in WPV against emergency nurses.10 In addition, long waiting time is a risk factor for ED WPV.11 Therefore, measures to mitigate potential violent patient behaviors should be incorporated into the prevention training,20 so that emergency nurses can alleviate the stress level in emergency departments to some degree. In addition, patients’ understanding of the triage process is also essential to avoiding violent conflicts in emergency departments. The majority of participants in the present study reported little faith in the commitment of hospital administrations to reducing WPV. To enforce the zero-tolerance policy, hospital managers must mobilize all resources to diminish the prevalence and severity of WPV against
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emergency nurses.21 Adequate communication between administrators and nurses not only improves nurses’ perception of feeling safe at work but also facilitates the development of prevention strategies.22 In addition, a stringent security system may alleviate the severity of WPV against emergency nurses, although it has not yet been shown to substantially reduce the prevalence of WPV in emergency departments.23
Limitations
Owing to the descriptive cross-sectional design of this study, no cause-effect relationship was explored. More analytic and cohort studies should be conducted to evaluate the effectiveness of current preventive measures, which may provide insights into the development of better strategies to prevent WPV against emergency nurses in Taiwan. In addition, the influence of culture on patients’ violent behavior, preventive measures, and the resilience of abused nurses all remain to be investigated.
Implications for Emergency Nurses
Based on the perception of emergency nurses, the current preventive measures in Taiwan against WPV in emergency departments are not effective. The reporting system should encourage abused nurses to report any type of WPV without hesitation. The content of a mandatory prevention training course should meet the needs of emergency nurses, thereby enabling them to mitigate violent patient behaviors and reduce the impact of WPV on nurses’ physical and emotional health. Conclusions
From the perspective of Taiwanese emergency nurses, hospital administrators must improve the reporting system, ED staff meetings, training courses, and communication between employers and employees to reduce the prevalence and severity of WPV against emergency nurses.
Author Disclosures
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Dr Han was funded by the Linkou Chang Gung Memorial Hospital, Taiwan; project title: Violence against
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nurses in emergency department in Taiwan; grant number is CMRPF1D0131. Conflicts of interest: none to report. REFERENCES 1. Groenewold MR, Sarmiento RFR, Vanoli K, Raudabaugh W, Nowlin S, Gomaa A. Workplace violence injury in 106 US hospitals participating in the Occupational Health Safety Network (OHSN), 2012-2015. Am J Ind Med. 2018;61(2):157-166. https://doi.org/10.1002/ajim.22798. 2. Ferri P, Silvestri M, Artoni C, Di Lorenzo R. Workplace violence in different settings and among various health professionals in an Italian general hospital: A cross-sectional study. Psychol Res Behav Manag. 2016;9:263-275. https://doi.org/10.2147/PRBM.S114870. 3. Shi L, Zhang D, Zhou C, et al. A cross-sectional study on the prevalence and associated risk factors for workplace violence against Chinese nurses. BMJ Open. 2017;7(6):e013105. https://doi.org/10.1136/bmjopen2016-013105. 4. Emergency Nurses Association. Position statement: violence in the emergency care setting. https://www.ena.org/docs/default-source/resourcelibrary/practice-resources/position-statements/violenceintheemergency caresetting.pdf. Published October 2014. Accessed January 16, 2019. 5. Copeland D, Henry M. Workplace violence and perceptions of safety among emergency department staff members: Experiences, expectations, tolerance, reporting, and recommendations. J Trauma Nurs. 2017;24(2):65-77. https://doi.org/10.1097/JTN.0000000000000269. 6. Wei CY, Chiou ST, Chien LY, Huang N. Workplace violence against nurses—Prevalence and association with hospital organizational characteristics and health-promotion efforts: Cross-sectional study. Int J Nurs Stud. 2016;56:63-70. https://doi.org/10.1016/j.ijnurstu.2015.12.012. 7. Li YF, Chao M, Shih CT. Nurses’ intention to resign and avoidance of emergency department violence: A moderated mediation model. Int Emerg Nurs. 2018;39:55-61. https://doi.org/10.1016/j.ienj.2017.09.004. 8. Hamdan M, Hamra AA. Burnout among workers in emergency departments in Palestinian hospitals: Prevalence and associated factors. BMC Health Serv Res. 2017;17(1):407. https://doi.org/10.1186/s12913-0172356-3. 9. Gacki-Smith J, Juarez AM, Boyett L, Homeyer C, Robinson L, MacLean SL. Violence against nurses working in US emergency departments. J Nurs Admin. 2009;39(7-8):340-349. https://doi.org/10.1097/ NNA.0b013e3181ae97db. 10. Pich JV, Kable A, Hazelton M. Antecedents and precipitants of patientrelated violence in the emergency department: Results from the Australian VENT Study (Violence in Emergency Nursing and Triage). Australas Emerg Nurs J. 2017;20(3):107-113. https://doi.org/10.1016/j.aenj. 2017.05.005. 11. ALBashtawy M, Aljezawi M. Emergency nurses’ perspective of workplace violence in Jordanian hospitals: A national survey. Int Emerg Nurs. 2016;24:61-65. https://doi.org/10.1016/j.ienj.2015.06.005. 12. Morphet J, Griffiths D, Innes K. The trouble with reporting and utilization of workplace violence data in health care. J Nurs Manag. 2019;27(3):592-598. https://doi.org/10.1111/jonm.12717. 13. Gillespie GL, Leming-Lee TS, Crutcher T, Mattei J. Chart it to stop it: A quality improvement study to increase the reporting of workplace
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aggression. J Nurs Care Qual. 2016;31(3):254-261. https://doi.org/10. 1097/NCQ.0000000000000172. 14. Han CY, Lin CC, Barnard A, Hsiao YC, Goopy S, Chen LC. Workplace violence against emergency nurses in Taiwan: A phenomenographic study. Nurs Outlook. 2017;65(4):428-435. https://doi.org/10.1016/j. outlook.2017.04.003. 15. Jeong IY, Kim JS. The relationship between intention to leave the hospital and coping methods of emergency nurses after workplace violence. J Clin Nurs. 2018;27(7-8):1692-1701. https://doi.org/10.1111/jocn.14228. 16. Hsieh HF, Chang SC, Wang HH. The relationships among personality, social support, and resilience of abused nurses at emergency rooms and psychiatric wards in Taiwan. Women Health. 2017;57(1):40-51. https://doi.org/10.1080/03630242.2016.1150385. 17. Hsieh HF, Hung YT, Wang HH, Ma SC, Chang SC. Factors of resilience in emergency department nurses who have experienced workplace violence in Taiwan. J Nurs Scholarsh. 2016;48(1):23-30. https://doi. org/10.1111/jnu.12177.
20. Krull W, Gusenius TM, Germain D, Schnepper L. Staff perception of interprofessional simulation for verbal de-escalation and restraint application to mitigate violent patient behaviors in the emergency department. J Emerg Nurs. 2019;45(1):24-30. https://doi.org/10.1016/j.jen.2018.07.001. 21. Morphet J, Griffiths D, Beattie J, Innes K. Managers’ experiences of prevention and management of workplace violence against health care staff: A descriptive exploratory study. J Nurs Manag. 2019;27(4):781-791. https://doi.org/10.1111/jonm.12761. 22. Havaei F, MacPhee M, Lee SE. The effect of violence prevention strategies on perceptions of workplace safety: A study of medical-surgical and mental health nurses. J Adv Nurs. 2019;75(8):1657-1666. https://doi. org/10.1111/jan.13950. 23. Gramling JJ, McGovern PM, Church TR, Nachreiner NM, Gaugler JE. Effectiveness of conducted electrical weapons to prevent violence-related injuries in the hospital. J Emerg Nurs. 2018;44(3):249-257. https://doi. org/10.1016/j.jen.2017.06.008.
18. Howerton Child RJ, Sussman EJ. Occupational disappointment: Why did I even become a nurse? J Emerg Nurs. 2017;43(6):545-552. https:// doi.org/10.1016/j.jen.2017.06.004.
Supplementary Data
19. Wu JC, Chen HY, Hsieh JL, Clinciu DL, Tung HH. Enhancing health care personnel’s response to ER violence using situational simulation. Clin Simul Nurs. 2019;28:6-14. https://doi.org/10.1016/j.ecns.2018. 12.003.
To access the supplementary material accompanying this article, visit the online version of the Journal of Emergency Nursing at www.jenonline.org.
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Appendix
SUPPLEMENTARY TABLE 1
Precipitating factors for WPV against emergency nurses Items n (%)
Environmental factors Location of your facility (rural, urban, suburban, etc.) Holding/boarding patients Insufficient/no quiet rooms No smoking policy affecting patients and families waiting in emergency department Crowding/high patient volume Insufficient/no seclusion rooms Lack of patient privacy No, or poorly enforced, visitor policy Violent crime rates (locally) Implementation of medical screening exams at triage Patient- and family-related factors Dementia/Alzheimer patients being cared for in emergency department Grieving families/visitors Limited/no access to food and beverages Patients/visitors under the influence of alcohol Patients’/visitors’ perception that staff is uncaring Perceived prejudice from nursing staff Misconception by patients/visitors of staff behavior Psychiatric patients being cared for in emergency department Patients’/visitors’ language/illiteracy problems Drug seeking behavior in patients Drug seeking behavior in families Cultural barriers Doctor, nurse, and patient relationship-related Not keeping patients/visitors informed Situations involving critically ill children Staff removing personal items from patients Perceived prejudice from nursing staff Unsatisfied with the care of ED registered nurses Unsatisfied with the care of other staff Administrative factors Collecting cash payment for ED visit Shortage of ED registered nurses Shortage of ED physicians Prolonged wait times
Total, n [ 407
168 (41.4) 348 (85.5) 38 (6.9) 25 (6.2) 278 (68.5) 42 (10.3) 73 (18) 133 (32.8) 39 (9.6) 170 (41.9) 119 (29.2) 232 (57.1) 43 (10.6) 360 (88.7) 189 (46.6) 231 (56.9) 206 (50.7) 199 (49) 198 (48.8) 96 (23.6) 171 (42.1) 88 (21.7) 96 (23.6) 25 (6.2) 24 (5.9) 135 (33.3) 210 (51.7) 231 (56.9) 54 (13.3) 285 (70.2) 211 (52) 294 (72.4)
RN, registered nurse; WPV, workplace violence.
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SUPPLEMENTARY TABLE 2
Influence of WPV on occupation selection in emergency nurses Item, n (%)
How likely is it that you would leave emergency nursing to work in a different unit in your hospital/facility because of WPV in your emergency department? Very likely Somewhat likely Somewhat unlikely Very unlikely Missing value How likely is it that you would entirely leave the emergency nursing profession because of WPV in your emergency department? Very likely Somewhat likely Somewhat unlikely Very unlikely Unknown Missing value
Total, n [ 407
15 (30.6) 24 (49) 8 (16.3) 2 (4.1) 358
37 (38.1) 53 (54.6) 6 (6.2) 1 (1) 222 88
WPV, workplace violence.
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SUPPLEMENTARY TABLE 3
Demographics, environment safety, and ED policy by type of WPV among RNs Items
Suffered verbal violence No, n [ 36
Yes, n [ 371 t
Suffered physical violence x2
p
No, n [ 101
Yes, n [ 306 t
x2
p
Age (years) 29.17 (7.77) 31.73 (7.33) -1.99 0.047 32.03 (8.22) 31.32 (7.10) 0.83 0.41 Nursing experience 5.92 (7.14) 9.57 (7.40) -2.84 0.005 9.37 (8.55) 9.21 (7.05) 0.18 0.86 (years) ED experience (years) 3.99 (5.37) 7.72 (6.49) -3.91 <.0001 7.30 (7.23) 7.44 (6.24) -0.19 0.85 Environment safety 5.79 (1.82) 4.25 (2.03) 4.27 <.0001 4.76 (2.16) 4.26 (2.01) 2.10 0.037 Needs met through 6.70 (2.11) 5.64 (2.23) 2.05 0.041 6.40 (1.99) 5.50 (2.27) 2.92 0.004 training Are the safety issues 0.211* 0.58 0.53 discussed in ED staff meetings? Yes 27 293 84 236 No 9 78 17 70 Does the hospital and 0.13 0.721 3.05 0.08 ED have WPV reporting guidelines? Yes 24 258 77 205 No 12 113 24 101 Is there a zero0.012 * 9.86 0.002 tolerance policy, that is, a policy mandating that any and all violent incidents directed at an RN in the ED are to be reported? Yes 23 156 58 121 No 13 215 43 185 Have you been 0.010 * 0.044 * instructed to report incidents of WPV you experience regardless of the type of violence or level of severity or harm? Yes 12 98 29 81 No 2 108 16 94 continued
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SUPPLEMENTARY TABLE 3
Continued Items
Suffered verbal violence No, n [ 36
Do you believe that your hospital administration is committed to eliminating WPV against RNs in the ED? Yes No Do you believe that your ED management is committed to eliminating WPV against RNs in the ED? Yes No
Yes, n [ 371 t
Suffered physical violence x2
p
No, n [ 101
Yes, n [ 306 t
0.020*
21 14
143 221
x2
54 46
110 189
0.059*
107 16
264 20
p
9.17 0.002
0.54*
90 33
216 68
Values are expressed as n or mean (SD). RN, registered nurse; WPV, workplace violence. * Analyzed by Fisher’s exact test, as >20% of the expected subjects was less than 5 in x2 test.
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WORKPLACE VIOLENCE AGAINST EMERGENCY NURSES IN TAIWAN: A CROSS-SECTIONAL STUDY Authors: Hui-Ling Lee, RN, MSN, Chin-Yen Han, RN, PhD, Bernice Redley, RN, PhD, Chun-Chih Lin, RN, PhD, Mei-Ying Lee, RN, MSN, and Wen Chang, RN, PhD, Taoyuan City, Taiwan, and Victoria, Australia
Methods: In this multicenter, descriptive, cross-sectional Contribution to Emergency Nursing Practice
The current literature on workplace violence against emergency nurses indicates that the phenomenon is common worldwide. This article contributes the main finding that Taiwanese emergency nurses are not satisfied with the current prevention measures implemented in emergency departments. The key implication for emergency nursing practice found in this article is that the measures should be reformed in order to reduce the impact of workplace violence against emergency nurses.
Abstract Introduction: Workplace violence against emergency nurses is common worldwide. This study aimed to gain a more thorough overview of the point prevalence of workplace violence against emergency nurses and the preventive measures used in emergency departments in Taiwan.
Introduction
Workplace violence (WPV) is verbal and physical violence against a person or persons on duty or at work, and incidents of WPV often occur in hospitals.1 Among health-care
Hui-Ling Lee is a Lecturer, Department of Nursing, Chang Gung University of Science and Technology, Taoyuan City, Taiwan. Chin-Yen Han is an Associate Professor, Department of Nursing, Chang Gung University of Science and Technology; and an Associate Research Fellow (joint appointment) Department of Nursing, Chang Gung Memorial Hospital at Linkou, Taoyuan City, Taiwan. Bernice Redley is an Associate Professor, Centre for Quality and Patient Safety Research — Monash Health Partnership, School of Nursing and Midwifery, Deakin University, Victoria, Australia. Chun-Chih Lin is an Associate Professor, Department of Nursing, Chang Gung University of Science and Technology; and an Associate Research Fellow (joint appointment) Department of Nursing, Chang Gung Memorial Hospital at Linkou, Taoyuan City, Taiwan.
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study, the questionnaire, Violence Against Nurses Working in Emergency Departments, was used to collect data from 407 nurses working at 5 emergency departments in Taiwan from May to October 2015. Results: The results revealed that 378 emergency nurses (92.9%) experienced workplace violence over the last 2 years. The average visual analog scale score (1-10) of security effectiveness in preventing workplace violence was 5.0 (SD ¼ 1.97). The average visual analog scale score of perceived safety level in terms of workplace violence was 4.38 (SD ¼ 2.06). The average visual analog scale score of meeting nurses’ needs was 5.72 (SD ¼ 2.23). Discussion: This questionnaire survey revealed that the cur-
rent preventive measures for workplace violence against emergency nurses in Taiwan were not effective. The relevant measures should be improved, thereby reducing the prevalence and severity of workplace violence against emergency nurses. Key words: Emergency department; Nurses; Questionnaire;
Workplace violence
personnel, nurses in particular are at high risk of WPV,2,3 and the prevalence rate of WPV-related injury in nurses is 1.7 times higher than in other health-care workers.1 WPV against nurses occurs more frequently in emergency departments than in other hospital departments in
Mei-Ying Lee is the Director, Department of Nursing, Saint Paul’s Hospital, Taoyuan City, Taiwan. Wen Chang is an Assistant Professor, Chang Gung University of Science and Technology, Taoyuan City, Taiwan. For correspondence, write: Wen Chang, RN, PhD, Chang Gung University of Science and Technology, 261 Wenhua 1st Road, Guishan Dist, Taoyuan City, Taiwan 33303; E-mail: [email protected]. J Emerg Nurs 2019;-:1-6. 0099-1767 Copyright Ó 2019 Emergency Nurses Association. Published by Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.jen.2019.09.004
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China, Italy, Taiwan, and the United States,2-6 suggesting a common phenomenon around the world. Emergency nurses can encounter WPV as often as daily,5 and 45% of abused emergency nurses suffered from depression, resulting in reduced enthusiasm and work satisfaction,7 quitting nursing,5 diminishing patient safety,8 and dampened quality of health care.8 Hence, the Emergency Nurses Association advocates a zero-tolerance policy for WPV.4 WPV against emergency nurses in Taiwan has been rarely explored. To provide a more thorough overview of the point prevalence of WPV against emergency nurses and the preventive measures implemented in emergency departments in Taiwan, the present multicenter crosssectional study was conducted.
Methods DESIGN
The present cross-sectional questionnaire survey included emergency nurses recruited from 2 public and 3 private hospitals in Taiwan and was conducted from May to October 2015. The study protocol was approved by the institutional review boards of all participating hospitals, and written informed consent was obtained from all participants. QUESTIONNAIRE
The self-reporting questionnaire Violence Against Nurses Working in Emergency Departments, developed by Gacki-Smith et al,9 was used to collect data. Face validity was assessed by 15 experts, and the instrument was revised based on their recommendations. The original English questionnaire was translated into Mandarin with the permission of Gacki-Smith, and back-translated into English. Five experts assessed the content validity of the questions using the content validity index (CVI) to determine applicability, clarity of expression, and content coverage. The Mandarin questionnaire was then revised as suggested by experts, and CVI values were calculated on the second assessment. Each question had a CVI value >0.8. The Cronbach’s alpha for the Likert scale questions (2, 6-8, 13, and 15) was 0.96, indicating good reliability and validity. Demographic characteristics were also collected. STATISTICAL ANALYSIS
The results of descriptive statistics were presented as frequency, percentage, mean, and SD. The required sample size was estimated using G*Power 3.1 software. Group dif-
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ferences were tested using t test and x2 analyses and analyzed by Fisher's exact test, as >20% of the expected subjects was less than 5 in the x2 test, a was set at 0.05 and power was 0.93-0.95. Statistical analyses were performed by using Statistical Package for Social Science (SPSS) version 19.0 (IBM Corp, Armonk, NY).
Results DEMOGRAPHIC PANTS
CHARACTERISTICS
OF
PARTICI-
A total of 440 questionnaires were distributed to emergency nurses at 5 hospitals, and 407 completed questionnaires were subject to final analysis. The mean age of the nurses was 31.50 (SD ¼ 7.0) years. Most participants were female (93.6%) and had a bachelor’s degree (73.9%). The mean nursing experience was 9.25 (SD ¼ 7.44) years, and the mean ED experience was 7.40 (SD ¼ 6.49) years. PREVALENCE OF WPV AGAINST EMERGENCY NURSES
The majority of emergency nurses experienced WPV (92.9%) within the past 2 years, and most WPV incidents occurred within the previous 6 months (41.6%). WPV incidents occurred most frequently during the afternoon shift (54.2%) and in the treatment area (61.2%). Most emergency nurses (58.5%) believed that WPV incidents had increased since last year. NURSES’ PERCEPTIONS ABOUT PREVENTIVE MEASURES IMPLEMENTED IN EMERGENCY DEPARTMENTS
The security effectiveness in preventing WPV was ranked using a visual analog scale (VAS) of 1-10 (1 ¼ not at all effective, 10 ¼ extremely effective), and the average VAS score was 5.0 (SD ¼ 1.97; Table 1). Participants ranked their safety levels in terms of preventing WPV by VAS 110 (1 ¼ unsafe, 10 ¼ extremely safe), and the average VAS score was 4.38 (SD ¼ 2.06). Only 69.8% of emergency nurses had received training for WPV prevention, and 46% of emergency nurses reported that the WPV prevention training was mandatory in their hospital. The average VAS score was 5.72 (SD ¼ 2.23) for the extent to which the WPV prevention training met the needs of emergency nurses (VAS, 1 ¼ did not meet needs, 10 ¼ fully met needs). In addition, 54.7% of participants discussed nurse safety in ED staff meetings daily or weekly (Table 1).
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TABLE 1
TABLE 2
Perception of registered nurses of the preventive measures against WPV implemented in emergency departments
Administrative issues surrounding preventive measures against WPV in emergency departments
Items
Is this a zero-tolerance policy, that is, a policy mandating that any and all violent incidents directed at an RN in the emergency department are to be reported? Yes No Missing value Do you believe that your hospital administration is committed to eliminating WPV against RNs in the emergency department? Yes No Missing value Barriers to reporting WPV* None/no barriers May affect customer service scores/reports Fear of retaliation from nursing staff Fear of retaliation from hospital administration Inconvenient/don’t want to deal with it Perceived as a sign of incompetence and weakness Violence comes with the job Ambiguous reporting policies No one reports these incidents Staff did not sustain any physical injury
Total, n [ 407
Does your hospital have a security system? Yes No The effectiveness of security in preventing violence against RNs in emergency departments (VAS 1-10) The overall level of safety from workplace violence in emergency department (VAS 1-10) Is your hospital training for the prevention/diffusion of violence in the emergency department mandatory? Yes No Missing value Where have you attended training/ course(s) for handling WPV prevention in the emergency department? Current hospital or other location Never attended How often is RN safety discussed in your ED staff meetings? Daily Weekly Monthly Quarterly Semi-Annually Annually Never Missing value
405 (99.5%) 2 (0.5%) 5.0 6 1.97
4.38 6 2.06
186 (46%) 218 (64%) 3
284 (69.8%) 123 (30.2%)
86 (22.6%) 129 (32.1%) 57 (14.2%) 63 (15.7%) 53 (13.2%) 8 (2%) 6 (1.4%) 5
Values were expressed as n (%) or mean 6 standard deviation. RN, registered nurse; WPV, workplace violence; VAS, visual analog scale.
In the present study, 226 (54.8%) participants claimed no hospital policy for reporting WPV against emergency nurses (Table 2). Only 39 (9.8%) emergency nurses recognized no barriers to reporting WPV. The commitment of the hospital administration to eliminating WPV against
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Total, n [ 407
Items
179 (44.2%) 226 (54.8%) 2
164 (41.1%) 235 (58.9%) 8 39 (9.8%) 90 (23.5%) 41 (10.3%) 110 (27.6%) 144 (36%) 107 (26.8%) 143 (35.8%) 90 (22.5%) 84 (21%) 292 (73%)
RN, registered nurse; WPV, workplace violence. * This is a multiple selection question.
emergency nurses was questioned by 235 (58.9%) participants (Table 2). PRECIPITATING FACTORS FOR WPV AGAINST NURSES IN EMERGENCY DEPARTMENTS
Precipitating factors for WPV against emergency nurses were classified as environmental, patient-related, caregiver-patient relationshiprelated, and administrative (Supplementary Table 1). The 3 most common
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precipitating factors were “patients/visitors under the influence of alcohol” (88.7%), “holding/boarding patients” (85.5%), and “prolonged wait times” (72.4%). Because of WPV, 79.6% of participants considered working in a department other than the emergency department, and 92.7% considered leaving the emergency nursing profession (Supplementary Table 2). DEMOGRAPHICS, ENVIRONMENTAL SAFETY, AND ED POLICY BY TYPE OF WPV
Among emergency nurses who experienced WPV, 371 (91.2%) suffered from verbal abuse and 306 (75.2%) suffered from physical abuse (Supplementary Table 3). Age, nursing experience, and ED experience were significantly greater in participants who were verbally abused than in those who were not (all P < 0.05). In contrast, no significant differences in age, nursing experience, or ED experience were observed between participants who encountered physical violence and those who did not. Significant differences were observed in the presence of a zero-tolerance policy between participants experiencing verbal abuse and those who did not (Fisher's exact test, P ¼ 0.01) and between participants experiencing physical abuse and those not (x2 ¼ 9.86, P ¼ 0.002). In addition, significant differences in being instructed to report WPV, the commitment of hospital administration, and the discussion of safety issues were also observed between those experiencing verbal abuse and those not, and between participants experiencing physical abuse and those who had not (all P < 0.05, Supplementary Table 3). Discussion
The present study found that 92.9% of 407 Taiwanese emergency nurses reported suffering from WPV within the last 2 years. Several cross-sectional studies also indicated high prevalence rates of WPV against emergency nurses worldwide.9-11 A cross-sectional study of 3,465 nurses who are members of the Emergency Nurses Association revealed that 70% of emergency nurses experienced WPV over the past 3 years.9 The Australian study Violence in Emergency Nursing and Triage (VENT) of 537 emergency nurses indicated that 87% of participants experienced WPV within the last 6 months.10 In addition, a survey of 227 Jordanian emergency nurses found that 75% experienced WPV.11 Despite the 24-hour security in emergency departments, our study participants did not feel safe in the emergency department, as evidenced by the average score of 4.38 for emergency nurses’ perceived safety level. By law, all
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emergency departments in Taiwan are required to be protected by security guards 24 hours a day, so “no security system” reported by 2 emergency nurses was due probably to a lack of awareness of the resource (Table 1). In the US, emergency nurses reported extreme dissatisfaction with workplace safety.9 The present study suggested that emergency nurses do not feel safe at work, which may in part be due to the lack of a hospital policy for reporting WPV and the perceived barriers to reporting WPV. An efficient reporting system is a critical component of a prevention strategy against WPV,12 and multiple forms of communication have been suggested recently to diminish the barriers to reporting WPV.13 Two studies of Taiwanese emergency nurses indicated that WPV not only caused emotional and physical injuries but also might drive nurses away from emergency nursing.7,14 Frequent exposure to WPV, either experiencing it or witnessing violent incidents, diminished the enthusiasm of emergency nurses.7,14 A Korean crosssectional study reported that 61.0% of abused emergency nurses considered leaving the nursing profession.15 In our study, 92.7% of participants also considered leaving the emergency nursing profession because of WPV. Peer support is essential to help abused emergency nurses strengthen their resilience to WPV in Taiwan,16 suggesting the potential role of ED staff meetings in reducing the negative impact of WPV. Two studies further suggested that hospital managers should encourage peer support and educate emergency nurses to examine their feelings, thereby improving their emotional health.17,18 Finally, a situational simulation training course is an effective tool for enhancing the coping skills of emergency nurses and thus a way to minimize the negative effects of WPV in Taiwan.19 This study found that alcohol, holding/boarding patients, and prolonged wait times were the 3 most common precipitating factors for WPV against emergency nurses. The Australian VENT study also stressed the stimulating role of alcohol in WPV against emergency nurses.10 In addition, long waiting time is a risk factor for ED WPV.11 Therefore, measures to mitigate potential violent patient behaviors should be incorporated into the prevention training,20 so that emergency nurses can alleviate the stress level in emergency departments to some degree. In addition, patients’ understanding of the triage process is also essential to avoiding violent conflicts in emergency departments. The majority of participants in the present study reported little faith in the commitment of hospital administrations to reducing WPV. To enforce the zero-tolerance policy, hospital managers must mobilize all resources to diminish the prevalence and severity of WPV against
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emergency nurses.21 Adequate communication between administrators and nurses not only improves nurses’ perception of feeling safe at work but also facilitates the development of prevention strategies.22 In addition, a stringent security system may alleviate the severity of WPV against emergency nurses, although it has not yet been shown to substantially reduce the prevalence of WPV in emergency departments.23
Limitations
Owing to the descriptive cross-sectional design of this study, no cause-effect relationship was explored. More analytic and cohort studies should be conducted to evaluate the effectiveness of current preventive measures, which may provide insights into the development of better strategies to prevent WPV against emergency nurses in Taiwan. In addition, the influence of culture on patients’ violent behavior, preventive measures, and the resilience of abused nurses all remain to be investigated.
Implications for Emergency Nurses
Based on the perception of emergency nurses, the current preventive measures in Taiwan against WPV in emergency departments are not effective. The reporting system should encourage abused nurses to report any type of WPV without hesitation. The content of a mandatory prevention training course should meet the needs of emergency nurses, thereby enabling them to mitigate violent patient behaviors and reduce the impact of WPV on nurses’ physical and emotional health. Conclusions
From the perspective of Taiwanese emergency nurses, hospital administrators must improve the reporting system, ED staff meetings, training courses, and communication between employers and employees to reduce the prevalence and severity of WPV against emergency nurses.
Author Disclosures
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Dr Han was funded by the Linkou Chang Gung Memorial Hospital, Taiwan; project title: Violence against
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nurses in emergency department in Taiwan; grant number is CMRPF1D0131. Conflicts of interest: none to report. REFERENCES 1. Groenewold MR, Sarmiento RFR, Vanoli K, Raudabaugh W, Nowlin S, Gomaa A. Workplace violence injury in 106 US hospitals participating in the Occupational Health Safety Network (OHSN), 2012-2015. Am J Ind Med. 2018;61(2):157-166. https://doi.org/10.1002/ajim.22798. 2. Ferri P, Silvestri M, Artoni C, Di Lorenzo R. Workplace violence in different settings and among various health professionals in an Italian general hospital: A cross-sectional study. Psychol Res Behav Manag. 2016;9:263-275. https://doi.org/10.2147/PRBM.S114870. 3. Shi L, Zhang D, Zhou C, et al. A cross-sectional study on the prevalence and associated risk factors for workplace violence against Chinese nurses. BMJ Open. 2017;7(6):e013105. https://doi.org/10.1136/bmjopen2016-013105. 4. Emergency Nurses Association. Position statement: violence in the emergency care setting. https://www.ena.org/docs/default-source/resourcelibrary/practice-resources/position-statements/violenceintheemergency caresetting.pdf. Published October 2014. Accessed January 16, 2019. 5. Copeland D, Henry M. Workplace violence and perceptions of safety among emergency department staff members: Experiences, expectations, tolerance, reporting, and recommendations. J Trauma Nurs. 2017;24(2):65-77. https://doi.org/10.1097/JTN.0000000000000269. 6. Wei CY, Chiou ST, Chien LY, Huang N. Workplace violence against nurses—Prevalence and association with hospital organizational characteristics and health-promotion efforts: Cross-sectional study. Int J Nurs Stud. 2016;56:63-70. https://doi.org/10.1016/j.ijnurstu.2015.12.012. 7. Li YF, Chao M, Shih CT. Nurses’ intention to resign and avoidance of emergency department violence: A moderated mediation model. Int Emerg Nurs. 2018;39:55-61. https://doi.org/10.1016/j.ienj.2017.09.004. 8. Hamdan M, Hamra AA. Burnout among workers in emergency departments in Palestinian hospitals: Prevalence and associated factors. BMC Health Serv Res. 2017;17(1):407. https://doi.org/10.1186/s12913-0172356-3. 9. Gacki-Smith J, Juarez AM, Boyett L, Homeyer C, Robinson L, MacLean SL. Violence against nurses working in US emergency departments. J Nurs Admin. 2009;39(7-8):340-349. https://doi.org/10.1097/ NNA.0b013e3181ae97db. 10. Pich JV, Kable A, Hazelton M. Antecedents and precipitants of patientrelated violence in the emergency department: Results from the Australian VENT Study (Violence in Emergency Nursing and Triage). Australas Emerg Nurs J. 2017;20(3):107-113. https://doi.org/10.1016/j.aenj. 2017.05.005. 11. ALBashtawy M, Aljezawi M. Emergency nurses’ perspective of workplace violence in Jordanian hospitals: A national survey. Int Emerg Nurs. 2016;24:61-65. https://doi.org/10.1016/j.ienj.2015.06.005. 12. Morphet J, Griffiths D, Innes K. The trouble with reporting and utilization of workplace violence data in health care. J Nurs Manag. 2019;27(3):592-598. https://doi.org/10.1111/jonm.12717. 13. Gillespie GL, Leming-Lee TS, Crutcher T, Mattei J. Chart it to stop it: A quality improvement study to increase the reporting of workplace
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aggression. J Nurs Care Qual. 2016;31(3):254-261. https://doi.org/10. 1097/NCQ.0000000000000172. 14. Han CY, Lin CC, Barnard A, Hsiao YC, Goopy S, Chen LC. Workplace violence against emergency nurses in Taiwan: A phenomenographic study. Nurs Outlook. 2017;65(4):428-435. https://doi.org/10.1016/j. outlook.2017.04.003. 15. Jeong IY, Kim JS. The relationship between intention to leave the hospital and coping methods of emergency nurses after workplace violence. J Clin Nurs. 2018;27(7-8):1692-1701. https://doi.org/10.1111/jocn.14228. 16. Hsieh HF, Chang SC, Wang HH. The relationships among personality, social support, and resilience of abused nurses at emergency rooms and psychiatric wards in Taiwan. Women Health. 2017;57(1):40-51. https://doi.org/10.1080/03630242.2016.1150385. 17. Hsieh HF, Hung YT, Wang HH, Ma SC, Chang SC. Factors of resilience in emergency department nurses who have experienced workplace violence in Taiwan. J Nurs Scholarsh. 2016;48(1):23-30. https://doi. org/10.1111/jnu.12177.
20. Krull W, Gusenius TM, Germain D, Schnepper L. Staff perception of interprofessional simulation for verbal de-escalation and restraint application to mitigate violent patient behaviors in the emergency department. J Emerg Nurs. 2019;45(1):24-30. https://doi.org/10.1016/j.jen.2018.07.001. 21. Morphet J, Griffiths D, Beattie J, Innes K. Managers’ experiences of prevention and management of workplace violence against health care staff: A descriptive exploratory study. J Nurs Manag. 2019;27(4):781-791. https://doi.org/10.1111/jonm.12761. 22. Havaei F, MacPhee M, Lee SE. The effect of violence prevention strategies on perceptions of workplace safety: A study of medical-surgical and mental health nurses. J Adv Nurs. 2019;75(8):1657-1666. https://doi. org/10.1111/jan.13950. 23. Gramling JJ, McGovern PM, Church TR, Nachreiner NM, Gaugler JE. Effectiveness of conducted electrical weapons to prevent violence-related injuries in the hospital. J Emerg Nurs. 2018;44(3):249-257. https://doi. org/10.1016/j.jen.2017.06.008.
18. Howerton Child RJ, Sussman EJ. Occupational disappointment: Why did I even become a nurse? J Emerg Nurs. 2017;43(6):545-552. https:// doi.org/10.1016/j.jen.2017.06.004.
Supplementary Data
19. Wu JC, Chen HY, Hsieh JL, Clinciu DL, Tung HH. Enhancing health care personnel’s response to ER violence using situational simulation. Clin Simul Nurs. 2019;28:6-14. https://doi.org/10.1016/j.ecns.2018. 12.003.
To access the supplementary material accompanying this article, visit the online version of the Journal of Emergency Nursing at www.jenonline.org.
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Appendix
SUPPLEMENTARY TABLE 1
Precipitating factors for WPV against emergency nurses Items n (%)
Environmental factors Location of your facility (rural, urban, suburban, etc.) Holding/boarding patients Insufficient/no quiet rooms No smoking policy affecting patients and families waiting in emergency department Crowding/high patient volume Insufficient/no seclusion rooms Lack of patient privacy No, or poorly enforced, visitor policy Violent crime rates (locally) Implementation of medical screening exams at triage Patient- and family-related factors Dementia/Alzheimer patients being cared for in emergency department Grieving families/visitors Limited/no access to food and beverages Patients/visitors under the influence of alcohol Patients’/visitors’ perception that staff is uncaring Perceived prejudice from nursing staff Misconception by patients/visitors of staff behavior Psychiatric patients being cared for in emergency department Patients’/visitors’ language/illiteracy problems Drug seeking behavior in patients Drug seeking behavior in families Cultural barriers Doctor, nurse, and patient relationship-related Not keeping patients/visitors informed Situations involving critically ill children Staff removing personal items from patients Perceived prejudice from nursing staff Unsatisfied with the care of ED registered nurses Unsatisfied with the care of other staff Administrative factors Collecting cash payment for ED visit Shortage of ED registered nurses Shortage of ED physicians Prolonged wait times
Total, n [ 407
168 (41.4) 348 (85.5) 38 (6.9) 25 (6.2) 278 (68.5) 42 (10.3) 73 (18) 133 (32.8) 39 (9.6) 170 (41.9) 119 (29.2) 232 (57.1) 43 (10.6) 360 (88.7) 189 (46.6) 231 (56.9) 206 (50.7) 199 (49) 198 (48.8) 96 (23.6) 171 (42.1) 88 (21.7) 96 (23.6) 25 (6.2) 24 (5.9) 135 (33.3) 210 (51.7) 231 (56.9) 54 (13.3) 285 (70.2) 211 (52) 294 (72.4)
RN, registered nurse; WPV, workplace violence.
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SUPPLEMENTARY TABLE 2
Influence of WPV on occupation selection in emergency nurses Item, n (%)
How likely is it that you would leave emergency nursing to work in a different unit in your hospital/facility because of WPV in your emergency department? Very likely Somewhat likely Somewhat unlikely Very unlikely Missing value How likely is it that you would entirely leave the emergency nursing profession because of WPV in your emergency department? Very likely Somewhat likely Somewhat unlikely Very unlikely Unknown Missing value
Total, n [ 407
15 (30.6) 24 (49) 8 (16.3) 2 (4.1) 358
37 (38.1) 53 (54.6) 6 (6.2) 1 (1) 222 88
WPV, workplace violence.
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SUPPLEMENTARY TABLE 3
Demographics, environment safety, and ED policy by type of WPV among RNs Items
Suffered verbal violence No, n [ 36
Yes, n [ 371 t
Suffered physical violence x2
p
No, n [ 101
Yes, n [ 306 t
x2
p
Age (years) 29.17 (7.77) 31.73 (7.33) -1.99 0.047 32.03 (8.22) 31.32 (7.10) 0.83 0.41 Nursing experience 5.92 (7.14) 9.57 (7.40) -2.84 0.005 9.37 (8.55) 9.21 (7.05) 0.18 0.86 (years) ED experience (years) 3.99 (5.37) 7.72 (6.49) -3.91 <.0001 7.30 (7.23) 7.44 (6.24) -0.19 0.85 Environment safety 5.79 (1.82) 4.25 (2.03) 4.27 <.0001 4.76 (2.16) 4.26 (2.01) 2.10 0.037 Needs met through 6.70 (2.11) 5.64 (2.23) 2.05 0.041 6.40 (1.99) 5.50 (2.27) 2.92 0.004 training Are the safety issues 0.211* 0.58 0.53 discussed in ED staff meetings? Yes 27 293 84 236 No 9 78 17 70 Does the hospital and 0.13 0.721 3.05 0.08 ED have WPV reporting guidelines? Yes 24 258 77 205 No 12 113 24 101 Is there a zero0.012 * 9.86 0.002 tolerance policy, that is, a policy mandating that any and all violent incidents directed at an RN in the ED are to be reported? Yes 23 156 58 121 No 13 215 43 185 Have you been 0.010 * 0.044 * instructed to report incidents of WPV you experience regardless of the type of violence or level of severity or harm? Yes 12 98 29 81 No 2 108 16 94 continued
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SUPPLEMENTARY TABLE 3
Continued Items
Suffered verbal violence No, n [ 36
Do you believe that your hospital administration is committed to eliminating WPV against RNs in the ED? Yes No Do you believe that your ED management is committed to eliminating WPV against RNs in the ED? Yes No
Yes, n [ 371 t
Suffered physical violence x2
p
No, n [ 101
Yes, n [ 306 t
0.020*
21 14
143 221
x2
54 46
110 189
0.059*
107 16
264 20
p
9.17 0.002
0.54*
90 33
216 68
Values are expressed as n or mean (SD). RN, registered nurse; WPV, workplace violence. * Analyzed by Fisher’s exact test, as >20% of the expected subjects was less than 5 in x2 test.
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