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The nurses' occupational experiences of violence set forth the reflection of their feelings and attitude toward themselves, the patient and how to take care of them. The aim of this study is to explain the nurses' experiences of violence in the therapeutic sections especially psychiatry. The results revealed that the violence is often exerted by the patients due to ectopic demands and the nature of their ailment. Nurses reported verbal violence more than the non-verbal one. In most of the cases, the nurses' first reaction, attempting to calm down the patient by talking to him/her, doesn't work and it often leads to fixing cases. The other results are deduced in four main concepts including the lack of adequate protection of the personnel, poor risk management, the outcomes of violence and humanitarian tendencies. Reinforcement of the management approaches in regular meetings, dealing with the inefficiencies, encouraging the staff, in-service training with an emphasis on the models pragmatically (by displaying) and the follow-up reports of the violent events are noticed with the most proper planning and organization.
Violence, nurses, psychiatry
Violence is rampant in any area of the social life, in all cultures and races. Nowadays, violence is considered as one of the issues related to the people's job safety and health. Violence at work is defined as following:
Aggressive measures including physical assault or threatening to do so in the work environment. Physical assault can be in the form of attacking people using hands and feet, kidnapping, murder, using the cold weapons and firearms as well as the tendency to hurt people including verbal, physical and written threats (NIOSH, 2002; Garnham, 2001; Distasio, 2002; Clements et al., 2005; Keely, 2002). Today, violence at work as a professional harmful factor, is counted as the warning of mental well-being all around the world. Violence can leave undesirable long-term consequences for the survivors that continue even after the end of the period; poor health, low quality of life and using more and more health care services are among the complication of violence (Maljers, 2006; Wells & Bowers, 2002; Cembrowicz & Shepherd, 1992; Whittington, Shuttleworth & Hill, 1996; Winstnaley & Whittington, 2004; Anderson & Parish, 2003; ILO, 2002).
The Consequences of Violence
Violence is along with multiple complications that affects the nurses and the manager of the systems. The consequences for the employees include reduction of working spirit, anger, reduction of self-confidence, being absent from work, changing job and even death (Stults, 1993; Tony, Fletcher, Samuel & James, 2000; Adib et al., 2002; Sendzum, 2005). In addition to the immediate harm caused by violence the number of times one faces with it at work can have cumulative impact on him, such that the more the frequency and the intensity of the incidence, the more the probability of trauma grows (Rippon, 2000).
The other consequences include negative behavioral manifestations. The professional violence can lead to burnout in nurses resulting in the loss of physical and emotional faculties and cause negative behaviors and attitudes toward himself and the others (Stults, 1993; Tony, Fletcher, Samuel & James, 2000).
The Extent and Causes of Violence
Although violence against nurses is a serious problem, the extent of violence against them and the risk of potential factors are uncertain. Nurses are the key members of the medical team who are responsible for the circadian treatment of the patients. They protect the patients to be able to get adaptable to the current situation and recover through their technical skills. In this regard, they gain lots of experiences along with solving problems and dealing with challenges (NIOSH, 2002; Garnham, 2001; Distasio, 2002). It is believed that they are constantly influenced by the factors of care service, in a way that some authors believe that the nurses are affected by the working environment in terms of psychosocial function (Garnham, 2001; Keely, 2002; Wells & Bowers, 2002).
The researcher's experiences that are the result of working in the hospital wards for many years reveal that most of the people don’t have a true concept of the medical staff's duties and in most cases they take the personnel for the doctor, thus they expect treatments and prescriptions of different medicine and if their expectations are not meet, they behave violently (Stults, 1993; Tony, Fletcher, Samuel & James, 2000). In other cases patients who have non-emergency states call the emergency services and if the personnel don’t hospitalize them or give them simple treatments, show violence (Stults, 1993; Tony, Fletcher, Samuel & James, 2000). However, as it was stated making any remark in this area requires conducting scientific researches. Nurses always deal with the patient's illogical behaviors and expectations and other occupational challenges in their sensitive and widespread working environment. The most outstanding examples of the challenges include assault, aggression, committing suicide, panic and the other problems with the hospitalized patients (Stults, 1993; Tony, Fletcher, Samuel & James, 2000). In this regard the studies reveal that most of the victims of the hospitalized patients' aggressive behavior are nurses and assistant staff (Tony, Fletcher, Samuel & James, 2000). The reports resulting from the researches in the psychological hospitals of London city manifested that, on average, two aggressive assaults take place per week, two third of which were related to the nurse staff (Tony, Fletcher, Samuel & James, 2000; Adib & Al- shafti, 2002). Such aggressive experiences may lead to chronic fatigue, quick temper, irritability, being angry with the patients and lack of sympathy for a nurse (Tony, Fletcher, Samuel & James, 2000; Rippon, 2000). Therefore, the medical care environment is full of violent and bizarre behaviors (Sands, 2007; Lavcus, 2006; Chapman & Style, 2006; Crilly, Chaboyer & C reedy, 2004; Celik, Celik, Agirbus & vgurluog, 2007; Kwok et al., 2006; Abbas, Fiala, Abdel Rahman & Fahim, 2010).
The Promotion of Professional Competences
Some people consider the deep understanding of the nurses' experiences necessary for promoting the professional competences, reinforcing the clinical decision making and reducing their working problems. In such a situation identifying the nurses' experiences in the ward shows what hardships they face with. In fact, we can analyze the pathology of the experiences through exploring them and specifying the overt and the covert dimensions. Considering the fact that the nurses' experiences are formed through the constant confrontation with the situations of the real world, expressing their experiences and feelings in terms of professional violence in the wards seems necessary. With regard to the negative effects of violence on the nurses' efficiency, the quality of the cares in the international hygiene organization, the nurses' international association, international labor organization and the international services were prioritized for conducting research in this area to minimize violence and its negative effects on the victims and the organizations (ILO, 2002).
The Psychiatry Nurses
Nurses are the key members of the psychiatry team and are responsible for the circadian treatment of the patients. They help the patients to be adaptable to the current situation and recover through their technical skills. They gain experiences in solving the problems and challenges of the psychiatry ward (Stuart & Laraia, 2005). it is believed that they are influenced by the health care factors constantly, such that some authors believe that the psychology ward's environment influences the psychosocial function of the nurses. The psychology ward's nurses always deal with the patient's illogical behaviors and expectations as well as the other professional challenges. Assault, aggression, committing suicide, panic and the problems of the hospitalized patients are the most outstanding examples of these challenges (Mehrabi, Fanian, Ghazavi & Zargham, 2007). In this regard, studies reveal that most of the victims of the assaults and aggressive behaviors in the psychology ward are the nurses and the assistant staff (McCarthy, 1985). MacKinnon believes that the psychology units' nurses are at the risk of verbal and physical aggression.
In Iran in order to assess the extent to which nurses were exposed to violence in instructional hospital in Tehran, the prevalence of the professional violence was estimated up to 69, 26 percent of which experienced verbal violence and bullying. (Teimourzadeh, Rashidian, Arba & Akbari, 2009)
In this regard, it is reported that the violent acts by the mentally ill patients can be conducive to tension, stress, burnout lack of job satisfaction and withdrawal from the patient. (McKinnon & Cross, 2008)
Since the nurses' experiences of violence in the psychiatry units set forth the reflection of their feelings, thoughts and attitudes toward the mental illnesses and how to take care of them, discovering them can be a good mean for evaluating and identifying the nurses' reaction in different situations and they make use of them in discovering and solving the problems of patients and themselves (Fry, Oriordan & Turner, 2002). Identifying the nurses' experiences in the psychiatry ward manifests the hardships they face. In fact, we can analyze the pathology of the experiences through exploring and clarifying the overt and the covert dimensions. Considering the fact that the nurses' experiences are formed by being exposed to the real life situations, expressing them is essential in terms of professional violence.
Hatch-Maillette and his associations argue that violence in the psychiatry ward is a permanent factor for the health care staff made mostly by the patient and to a less extent their visitors. (Hatch- Maillette, Scalora, Bader & Bomstein, 2007)
The study's findings include the presumption of four main concepts of lack of adequate protection, poor risk management, the outcomes of violence and humanitarian tendencies. The results suggest that the nurses indicated the head's and the hospital's lack of attention to the problems. Ryan and his associations state that some environmental factors including too much work, hard working conditions, work pressure, increasing the patients’ day-by-day and lack of adaptability to the nurse can lead to violence, incline the patients to aggression and affect them both physically and mentally (Ryan, Hills & Webb, 2004).
It is believed that the shortage in the number of staff and the load of work caused that the technical duties during the working shifts affect the nurse's performance. This makes the nurse pay attention to the emotional needs of the patient during the technical cares (Aien, Alhani, Mohammadi & Kazemnejad, 2008).
In his study 62 percent of the nurses believe that too much work is responsible for their failure in controlling the ward, thus the outrage of the violence in the patients and 18 percent complained about the physical problems (Owen, Jones & Tennant, 1998).
Today, nursing as a routine based job, has been mentioned as a serious deficiency that can be resulted from the shortage in the number of staff and too much work. So everybody is trying to replace it with being patient based with an emphasis on the patient and his/ her unique needs (Nikbakht, Parsa Yakta, Emami, 2004).
Legal problems resulting from the patients' quarrel with the staff and not being supported by the heads are some of the participants' obsession which is also indicated in the study of Teimourzadeh and his colleagues (Teimourzadeh, Rashidian, Arba & Akbari, 2009). In this regard Paterson believes that presence of the managers brings power and ease for the nurses, for they are the only dynamic element in the working lives of nurses and their presence is a key factor in the process of adaptability to the professional violence (Stuart & Laraia, 2005).
MacKinnon stated that the managers should understand the depth of the nurse's anger, fear and stress in that condition and give him/her sympathetic responses to create the feeling of being supported by them. As the nurses are not satisfied with the head's support and dealing with the problem, in most of the cases they don't report the above-mentioned events. In a study Teimourzadeh and his colleagues reported that in 40 percent of the cases the manager adopts no policy in terms of the nurses' health and safety, so they believe that reporting the events is useless (Teimourzadeh, Rashidian, Arba & Akbari, 2009).
The most important weakness in reporting is that the managers don’t pay attention to them and don’t follow up (McKinnon & Cross, 2008).
To confirm this matter there are more studies (McCarthy, 1985; Teimourzadeh, Rashidian, Arba & Akbari, 2009; Fry, Oriordan & Turner, 2002; Nolan, 2001; Delaney, Cleary, Jordan & Horsfall, 2001). The data represented that the participants themselves understand each other's spiritual needs and support each other. Fray pointed out that a nurse is the most important source of emotional support for the patient and the other nurses (Fry, Oriordan & Turner, 2002). It seems that the lack of satisfaction with this basic need was being compensated this was. Other data include poor professional skills' instruction and risk management. Ian quoted Walsh 5 "although the technical skills of the nurses are out of question, sometimes their communication abilities are so weak that fails to respond to the unique needs of each patient. In this case nurses need to gain skill and knowledge in this regard.
The author has mentioned that according to the student model, the complicated skills occur through observing the role model's function, practicing them and receiving feedback from the instructor. (Aien, Alhani, Mohammadi & Kazemnejad, 2008)
In a study Freshwater and Stickle stated that EQ influences the nurses' function, thus if the communication skills are inadequate, the nurse will be benefited by the individual feelings which are kind of EQ (Aien, Alhani, Mohammadi & Kazemnejad, 2008).
The participant's remarks represent their failure in the prevention of anger and controlling the impulses. Training anger management is applicable to develop anger management skills and reduce the vulnerability of normal people or the specific groups of clinical population, Del Vecchio writes. He adds, this method is suitable for those who don’t have adequate skill in anger management and are afflicted by some physical or behavioral disorders as a result of anger arousal and improper expression of that as well as the extreme internalization and externalization (Del Vecchio & Oleary, 2004).
In Naveedy's study it was specified that nearly 80 percent of the adults and teenagers participated in the training courses attained the skill in controlling anger, problem-solving, empathy, assertiveness and self-comfort. The frequency and the intensity resulting from the externalization of anger including maladaptive behaviors decreased among them (Naveedy, 2008). According to the analysis of the information, aggressive situations lead to the loss of physical and mental power in nurses. Rafiee and his colleagues quoted Pouter 3 "feeling of deprivation, depression, stress and trifling physical complaints are the normal parts of life and work. However, those who are affected by the professional burnout, experience these negative feelings more than others until the signs become chronic in them (Rafiee, Haghdoost & Yadvar, 2006). The results of some studies suggest that nurses, the psychiatry staff in particular, who deal with imbalanced and psychotic patients are increasingly at the risk of physical and emotional problems (Stuart & Laraia, 2005; McCarthy, 1985; Delaney, Cleary, Jordan & Horsfall, 2001; Ahangarzadeh, Shams & Saghizadeh, 2008; Yosefi, Namdari & Adhamian, 2006).
Another outcome of violence is negative behavioral manifestation. The professional violence can lead to burnout in the staff resulting in the loss of one's physical and emotional power and the incidence of negative behaviors and attitudes toward himself and the others. (Ahangarzadeh, Shams & Saghizadeh, 2008; Hashemzadeh, Orangi & Bahredar, 2001) in a study that reflects the experiences of the nurses in the psychiatry ward regarding violence, the physical, emotional and psychological harm led to the premature resignation from the job (Henk, Len, Nico & Gerard, 2005).
Although there is no exact statistics from the nurses' behavioral problems in Iran, in a study carried out on the nurses of the emergency wards of Alberta hospital in Canada it was manifested that 42 percent showed violent behaviors and the reasons were first, the patient then, colleagues and more seriously their families (mostly as a quarrel) (Hesketh et al., 2007).
The center for feeling self-sufficiency described nurses as worthiness, success and job satisfaction, ability to distinguish and perceive, increasing job performance and adds that the loss of job interest and job aversion are the results of the lack of chronic control on job success (Mercer, 2007).
In the study by Visy and his associations there has been a significant negative relationship between the severe tensions at work and the job satisfaction (Veisi, Atef, Kazem & Rezai, 2001)
Many of the nurses in describing their experiences of the violent situations had positive view to the patient that was expressed as moral attitudes and feelings as well as altruism toward the mentally ill. With oppose to the study of Rafiee and his colleagues in which the nurses of the burning ward were heedless of the patient's problems, they didn’t sympathized with the patients and avoided them in order to reduce their own tension (Rafiee, Haghdoost & Yadvar, 2006).
Emergency is the point of connection between the people and the health care system (Gulrajani, 1995). Due to the specific nature of emergency cares, most of the people who call the system are suffering from physical, psychological and social disorders. Therefore, the emergency room is full of abnormal behaviors including the aggressive ones (Sands, 2007).
Violence against the medical personnel is a global issue which is increasing (Whittington & Wyker, 1996). For example, the criminology association of Australia considers these institutions as the crime center (Jones & Lyneham, 2001). Among the health care personnel also the emergency wards are mostly exposed to violence (Chapman & Style, 2006). The main reasons of violence in the emergency room include increasing the time of expectation, the patient's hopelessness, the poor disciplinary system, silence culture, lack of reporting system and lack of the head's sensitivity to violence (Jones & Lyneham, 2001).
The emergency personnel are always exposed to violence because of being in the streets and even people's houses (Lucas, 2001). For example, one of the U.S news channels in 2007 reported 27 violent assaults with knife against the personnel in the emergency room (ABC News, 2009).
One kind of violence is the verbal one which has destructive effects on the personnel. For example, studies on verbal violence against the ambulance staff in the U.S showed that 61 percent of them are exposed to the verbal violence annually (Corbett, Grange & Thomas, 1998; Mechem, Dickinson & Shofer, 2002). In addition, a study carried out in Sweden revealed that in the three years 80 percent of the ambulance staffs are exposed to violence by the patients, their families and friends (Boyle, Koritsas, Coles & Stanely, 2007).
The conducted researches in different countries in terms of the prevalence of verbal violence represented a high frequency (Crilly, Chaboyer & C reedy, 2004; Boyle, Koritsas, Coles & Stanely, 2007; Pozzi, 1998). For example, Suserud showed that the prevalence of verbal violence against the emergency personnel in Sweden was 78 percent during a year (Suserud, Blomquist & Johansson, 2002).
Moreover, the results of Boil and his association's study represented that 82, 4 percent of the emergency personnel experienced verbal violence in a year (Boyle, Koritsas, Coles & Stanely, 2007). The studies carried out on nurses revealed that in the personnel's view the patient's death, accessibility of their work place and working in the places with high violence are effective in the creation of violence against them (Zamanzadeh, Soliman-Nejad & Abdullah-Zadeh, 2007). Pozzi in his study also specified that 71 percent of the personnel didn’t report any violence (Pozzi, 1998).
Age, Gender, Working Hours and Violence
In some studies there is no relationship between age and the patients' violence (Erkol, Gokdogan, Erkol & Boz, 2007). However, in some others (Estryn-Behar et al., 2008; Tang, Chen, Zhang & Wang, 2007), in case of the young nurses, the violence of the patients or their associates were high. In addition, in this study there was no significant difference between the two genders in terms of the psychological violence of the patients or their associates. (Adib et al., 2002; Estryn-Behar et al., 2008; Shoghi et al., 2008).
In other studies violence of the patients or their associates were more in male nurses than the in female ones. Even in some studies (Pozzi, 1998), there was no relationship between gender and the outrage of violence. The reason for such a difference can be the different cultures.
In other study (Estryn-Behar et al., 2008) the working hours of nurses were divided into less than 35 hours, more than or equal to 35 hours per week on average and there was a significant relationship between the working hours and the incidence of violence against the participants in this study. In a study (Shoghi et al., 2008) the working hours were divided as less than 176, 177-250 and 250-520 hours.
The results of this study represents high incidence of verbal violence against the medical personnel. This suggests the necessity of carrying out immediate measurements for the reduction of the violence. In addition, it is suggested that the viewpoints of the patients and their families regarding the causes of violent actions against the personnel and people's awareness in terms of the personnel's duties are explored.
Violence against nurses is a serious and common problem, hence further studies in this area to find some approaches to minimize that will be useful individually, socially and economically.
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