School of Nursing

Faculty of Health Science

Why do nurses electronically chart violence alerts on,

or 'flag', emergency patients?

April Stanley-Banks

December 2011

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TABLE OF CONTENTS

CHAPTER 1: INTRODUCTION .................................................................................... 1

1.1 Introductory Paragraph ................................................................................. 1 1.2 Context of the Study ....................................................................................... 3 1.3 Purpose of the Study ....................................................................................... 5 1.4 Statement of the Research Question ............................................................. 7 1.5 Statement of the Hypothesis .......................................................................... 8

1.6 Significance of the Study ................................................................................ 9

1.7 Assumptions .................................................................................................. 12

1.8 Definitions of Terms and Cases ................................................................... 12 1.9 Summary of the Thesis ................................................................................. 16 1.10 Conclusion ..................................................................................................... 18

CHAPTER 2: LITERATURE REVIEW ....................................................................... 20 2.1 Introduction to the Literature Review ........................................................ 20

2.2 Environmental Factors Related to Emergency Department Violence ..... 23 2.3 Media Portrayal of Community Violence................................................... 26 2.4 The Healthcare Approach to Emergency Department Violence .............. 27 2.5 Impact of Workplace Violence on Emergency Nurses .............................. 31

2.6 Implications for Emergency Nurses ............................................................ 33

2.7 Summary ....................................................................................................... 35

CHAPTER 3: METHODOLOGY AND METHODS ................................................... 36 3.1 Introduction................................................................................................... 36

3.2 Research Paradigm for this Study .............................................................. 37 3.3 Research Design and Methodology ............................................................. 38 3.4 Research Tool Development ........................................................................ 39

3.5 Study Setting/Research Site ......................................................................... 41 3.6 Study Population ........................................................................................... 43

3.7 Inclusion/Exclusion Criteria ........................................................................ 43 3.8 Recruitment Strategies ................................................................................. 45 3.9 Ethics Approval ............................................................................................ 46

3.10 Approval from the Ethics Committee ......................................................... 47 CHAPTER 4: RESULTS ............................................................................................... 57

4.1 Introduction................................................................................................... 57

4.2 Study Sample ................................................................................................. 57 4.3 Section A1 Emergency Nurse Participant Demographics ........................ 59 4.4 Section A2 ‘Flagging’ ................................................................................... 69 4.5 Section B: Patient-related Factors .............................................................. 70

4.6 Section C: Nurse Attitudes, Practice and Knowledge of ‘Flagging’ in the

ED 73 4.7 Section D Nurse Perception of Flagging in the ED .................................... 76 4.8 Analysis of Focus Group Interviews ........................................................... 79

4.9 Conclusion ..................................................................................................... 90 CHAPTER 5: DISCUSSION ........................................................................................ 92

5.1 Restatement of the Problem ......................................................................... 92 5.2 Summary Description of Procedures .......................................................... 94

5.3 Major Findings and Their Significance to Clinical Practice .................... 95

5.4 Study Limitations/Strengths ...................................................................... 102 5.5 Recommendations for Further Investigation ........................................... 103 5.6 Conclusion ................................................................................................... 104

APPENDICES .............................................................................................................. 123 Appendix 1: Aggression and Violence Incident Report Form (IF 18) page 1 .. 124

Appendix 1: Aggression and Violence Incident Report Form (IF 18) page 2 .. 125 Appendix 1: Aggression and Violence Incident Report Form (IF 18) page 3 .. 126 Appendix 1: Aggression and Violence Incident Report Form (IF 18) page 4 .. 127 Appendix 2: Research Questionnaire .................................................................. 128 Appendix 3: Focus Group Interview Questions .................................................. 125

Appendix 4: ED Violence Incidents Data ............................................................ 126

Appendix 4: ED Violence Incidents Data ............................................................ 127

Appendix 4: ED Violence Incidents Data ............................................................ 128 Appendix 5: Newspaper Articles .......................................................................... 129 Appendix 5: Newspaper Articles .......................................................................... 130 Appendix 5: Newspaper Articles .......................................................................... 131 Appendix 5: Newspaper Articles .......................................................................... 132

Appendix 6: Advertisement for Survey Participant Recruitment .................... 133 Appendix 7: Willingness to Participate in Focus Group Interview Form ........ 134 Appendix 8: Participant Information Sheet ........................................................ 135 Appendix 9: Research Proposal, page 1 .............................................................. 137

Appendix 9: Research Proposal, page 2 .............................................................. 138

Appendix 9: Research Proposal, page 3 .............................................................. 139

Appendix 9: Research Proposal, page 4 .............................................................. 140 Appendix 9: Research Proposal, page 5 .............................................................. 141

Appendix 9: Research Proposal, page 6 .............................................................. 142 Appendix 9: Research Proposal, page 7 .............................................................. 143 Appendix 9: Research Proposal, page 8 .............................................................. 144

Appendix 10: University of Adelaide Ethics Committee Approval .................. 145

Appendix 11: CNAHS Ethics Approval/Hospital Setting Willingness to Support

.................................................................................................................................. 146

Appendix 11: CNAHS Ethics Approval/Hospital Setting Willingness to Support

.................................................................................................................................. 147

Appendix 12: Pilot Questionnaire, page 1 ........................................................... 148 Appendix 12: Pilot Questionnaire, page 2 ........................................................... 149 Appendix 12: Pilot Questionnaire, page 3 ........................................................... 150

Appendix 12: Pilot Questionnaire, page 4 ........................................................... 151 Appendix 12: Pilot Questionnaire, page 5 ........................................................... 152 Appendix 12: Pilot Questionnaire, page 6 ........................................................... 153 Appendix 12: Pilot Questionnaire, page 7 ........................................................... 154 Appendix 12: Pilot Questionnaire, page 8 ........................................................... 155

Appendix 12: Pilot Questionnaire, page 9 ........................................................... 156 Appendix 13: Australian Nursing Federation Policy, page 1 ............................ 157 Appendix 13: Australian Nursing Federation Policy, page 2 ............................ 158

Appendix 13: Australian Nursing Federation Policy, page 3 ............................ 159 Appendix 13: Hospital Policy, Personal Threat Action Card 1......................... 160 Appendix 13: Hospital Policy, Personal Threat Action Card 2......................... 161 Appendix 13: Hospital Policy, Personal Threat Action Card 3......................... 162

Appendix 13: Hospital Policy, Personal Threat Action Card 4......................... 163

Appendix 13: Hospital Policy, Personal Threat Action Card 5......................... 164 Appendix 13: Hospital Policy, page 1 of 3 ........................................................... 165 Appendix 13: Hospital Policy, page 2 of 3 ........................................................... 166 Appendix 13: Hospital Policy, page 3 of 3 ........................................................... 167 Appendix 14: Participant Response to Item B1.2 ............................................... 168

Appendix 15: Focus Group In-House Nurse-to-Nurse Discussions .................. 169

Appendix 15: Focus Group In-House Nurse-to-Nurse Discussions (continued)

.................................................................................................................................. 170

LIST OF FIGURES

Figure 1: Emergency Nurse Flagging Behaviour and Patient Related Behaviours ....... 72 Figure 2 Flow Chart of Major Themes stemming from the experience of Workplace

Violence .................................................................................................................. 82

LIST OF TABLES

Table 1 Response Rate by Emergency Nurse Classification .......................................... 58

Table 2 Demographic Summary of 85 Emergency Nurses including Age, Gender and

Career Experience ................................................................................................... 60 Table 3 Emergency nurse Flagging Behaviour (including Recency and Frequency of

Flagging) in relation to Demographics ................................................................... 62 Table 4 Emergency Nurse Flagging Behaviour (including recency and frequency of

Flagging) in Relation to Experience ....................................................................... 63

Table 5 Flagging Behaviour/Participant Demographics including Shifts Worked and

Qualifications .......................................................................................................... 68 Table 6 Emergency Nurse Reasons for Not Flagging .................................................... 69 Table 7 Patient-related Factors Ever, Always and Never Flagged ................................. 70 Table 8 Emergency Nurse Attitudes to Flagging ........................................................... 74 Table 9 Emergency Nurse Practices of Flagging ........................................................... 75

Table 10 Emergency Nurse Knowledge of Flagging ..................................................... 76 Table 11 Emergency Nurse Perception of Flagging ....................................................... 78

STATEMENT OF ORIGINALITY

ACKNOWLEDGEMENTS

Numerous people have assisted with the completion of this thesis through the provision

of support, motivation and assistance.

First and foremost, I would like to express my sincere gratitude to my supervisors Dr

Timothy Schultz and Ms Tiffany Conroy for their valuable guidance, encouragement,

advice and inspiration.

I also thank the Acting Nursing Director for the Emergency Department; Andrew

McGill for supporting the research proposal and the ongoing research project.

I would like to take this opportunity to express my gratitude to the nurses who took the

time to participate and impart their knowledge and experience in the data collection

period of this research.

I would also to thank Professor Judy Magarey for her assistance in the introduction of

statistical analysis and Associate Professor Anne Wilson for her support throughout the

research project phase.

I deeply thank my husband and family members for their support and encouragement.

ABSTRACT

Background

The emergency department workplace violence is an increasing universal experience for

nurses inducing negative consequences such as feelings of vulnerability amongst nurses.

Little is known about this problem due to varying definitions of workplace violence,

variable data collection and under-reporting of violence incidents by nurses. Some

reasons given for under-reporting are; what nurses ascribe to acts of violence, individual

desensitisation to violence, and nurses considering it to be a part of the job. The

Emergency Department Information System is a readily available electronic reporting

system used frequently by ED nurses to highlight or „flag‟, patients who exhibit

potential for violence. This tracking system assists the nurse to identify and manage

potential violence by equipping the nurse with prior knowledge regarding such patients.

Aims

The aims of this study are to better understand why emergency nurses „flag‟ patients in

the ED and what factors trigger emergency nurses to „flag‟.

Methodology

In this mixed methods study, quantitative, (self-reported questionnaires), and

qualitative, (semi-structured focus group interviews), data collection techniques were

used.

Findings

Findings from this study indicated that nurses „flag‟ to protect themselves and their

colleagues from being targets of violent attack. Nurses who didn‟t „flag‟ were unaware

of the „flagging‟ process. Most nurses were unaware of a hospital policy for the process

of „flagging‟. Although „flagging‟ is a means by which nurses alert themselves to

identified cues for potential violence, „flagging‟ did not allay fears or feelings of

vulnerability amongst nurses.

Conclusion

Despite the use of the „flagging‟ process, „flagging‟ was not an established means of

prevention or a solution to violence. „Flagging‟ was considered as a means of improving

safety in the ED and therefore used by nurses, but it was merely a warning of presence

of violence in the ED. Since „flagging‟ had no impact on levels of nurse vulnerability,

more research needs to be done in order to assist to increase rates of emergency nurse

safety and retention and best patient outcome.

DEDICATION

I wish to dedicate this work to my sons Bill and Tom, and to my son-in-law Gav and to

my husband‟s son Trev whose experiences as young men inspired me.

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CHAPTER 1: INTRODUCTION

1.1 Introductory Paragraph

Despite a growing global unity for a covenant covering citizens‟ rights to occupational

safety, (Patterson, Leadbetter & Miller 2005), literature identifies emergency

departments as having escalated risk for incidents of workplace violence (Catlette 2005;

Erickson & Williams-Evans 2000; Ferns 2005a; Gerberich et al 2005; Lyneham 2000 &

McPhaul & Lipscomb 2004). Causes of workplace violence are depicted by

international research as burgeoning overcrowding, (due to increasing populations),

overwhelming shortages in healthcare resources and staff, (creating heavier workloads),

and spiralling numbers and seriousness of cases associated with substance abuse,

psychiatric disorders and interpersonal violence (Camerino et al 2008; Chapman &

Styles 2006; Crilly, Chaboyer & Creedy 2004 & Di Martino 2003). Emergency nurses,

who practice in the front line of patient care, and are exposed to first hand experiences

of workplace violence on a daily basis, are known to under-report these incidents and

suffer negative experiences such as increased feelings of personal vulnerability at work

and psychological and social dysfunction (Camerino et al 2008; Glaister & Kesling

2002; Hislop & Melby 2003; Luck, Jackson & Usher 2007 & Secker et al 2004).

Barriers to reporting include nurse perceptions of managerial and hospital

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administration abandonment in these matters (Cooper et al 2011; Jacobson 2007; Jones

& Lyneham 2000; King et al 2006 & McKoy & Smith 2001). As well as under-

reporting, a scarcity of standardized measurement and reporting mechanisms for

violence in healthcare settings exists (Duxbury 2003; Ferns & Chojnacka 2005; Ferns

2006; Gacki-Smith et al 2009; Kennedy 2005 & Wilkes et al 2010). As a result, two

issues are of main interest: nurse reporting concerning the incidence of workplace

violence and impact of workplace violence on nursing performance. The findings of an

exploratory case study by Mayhew and Chappell in 2003, (which incorporated the

International Labour Office, the International Council of Nurses, the World Health

Organization and Public Services International), on the experience of occupational

violence of health care workers in Australia, are consistent with international research.

Major findings reveal that violence experienced by Australian health care workers is

complex and risk factors undetermined. Findings reveal the following points of

significance;

perpetrators of occupational violence have particular characteristics

assaults are predominantly instigated by patients suffering from mental

health conditions and are drug/alcohol-affected

patient-initiated violence is relatively common

perpetrators are disproportionately male

reporting is unreliable.

It is unknown whether incidents of unaddressed, antisocial or hostile behaviour toward

nurses from patients induces an element of marginal care in return (Benson et al 2003;

Di Martino 2003; Erickson & Williams-Evans 2000; Holmes 2006; Luck, Jackson &

Usher 2007 & Winstanley & Wittington 2004). It is also uncertain if nurses perceive

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these patient behaviours as triggers for marginal care, to what degree nurses justify

marginal care in terms of self-defence, and how nurses may recommend the decision for

a culture of marginal care and communicate this among themselves as a means of mob

protection (Alexander et al 2004; Keely 2002; McPhaul & Lipscomb 2004; Roche,

Diers & Catling-Paull 2010). This chapter will describe the context, purpose, research

questions and significance of this thesis. Assumptions, definitions of terms and a

summary of the thesis are also presented.

1.2 Context of the Study

A male adolescent gang member presented to the emergency department with serious

injuries sustained in physical assault. He had been beaten around the head and chest by

multiple perpetrators using metal rods as weapons. This patient‟s background involved

a number of family, social and environmental conditions which he blamed for inhibiting

his personal development. These conditions were likely to have resulted in his poor

integration as a valuable citizen into society. Not only had this marginalization

increased this young man‟s propensity for engagement with criminal violence, but it

fuelled disparagement towards him from nursing staff while in the emergency

department for treatment of his injuries. His delinquent criminal behaviour had been

documented in his case notes during his previous presentations to this hospital facility.

As well as this, his associated past expressions of verbal aggression and physical

violence toward nursing staff had been recorded by nurses using an electronic system

for placing violence alerts on such individuals. The moment this young male arrived at

the emergency department for treatment, was triaged by the triage nurse, and had his

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details linked by the receptionists to his admission via HASS, (Hospital Admission

Software Service), the violence alert, already in place, was immediately activated and

became visible to all nursing staff. The patient however, had no knowledge of this

insight gained by nurses. Following a brief initial medical assessment of injuries and

primary survey by emergency department staff, nursing interventions continued which

included the monitoring of his haemodynamic status and attempts to reduce his

perceived pain levels while waiting for blood and x-ray test results. Throughout his stay

in the emergency department the patient regularly expressed increased feelings of

ostracism from emergency department nurses and their care delivery. As his complaints

became louder, they were addressed less. He began to yell at the nursing staff in

retaliation and threatened their safety. Security staff were promptly called by nursing

staff to the patient‟s area to assist with prevention of harm to himself and others. The

interaction by the two security guards led to the patient removing himself from the

emergency department in an eruption of violent disarray despite the need for treatment

of his serious injuries. His self-discharge from the hospital facility, prior to complete

medical and surgical assessment and intervention, subsequently placed this patient at

risk of a reduced chance of survival. His self-discharge was clinically noted as „left

before treatment complete‟. Since the number of male, adolescent violence-related

presentations to the emergency department, (where the researcher is employed), is

perceived by nursing staff to be increasingly prevalent and the health care response to

this presenting population has been less than successful in its treatment outcomes, (since

the majority of these clients leave the department before their injuries are appropriately

assessed and/or treated), the existence of a relationship between the factors „violent

patients‟, „nurse behaviour‟ and „care delivery‟ was suspected by the researcher. This

observation led to the formulation of a research topic which endeavoured to examine

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emergency nurse perspectives on presentations to emergency departments involving

violent patients and the subsequent behaviour in emergency nursing practice and patient

outcome. The following questions became of main interest;

Does patient association with violence intimidate nursing staff and lead to

compromised access to legitimately entitled health resources?

Do emergency nurses, who are often placed in dangerously threatening

situations by violent patients, use alerts or „flags‟ as indicators for self-

protection during nursing intervention?

Does the impact of frequent exposure to violent patients cause emergency

nurses to change their reporting behaviours?

Do emergency nurses place alerts on, or „flag‟, these patients as a means to

reduce fear of attack and/or risk of becoming targets of violence?

1.3 Purpose of the Study

The research topic initially endeavoured to cover aspects of emergency nurse

perspectives of emergency department presentations involving adolescent male victims

and perpetrators of interpersonal violence. The researcher was concerned for the health

care response and outcome of injuries sustained during these acts of violence for this

population as well as the influence nurse exposure to acts of violence may have on

nurses and their nursing care delivery. In order to capture an in depth insight on this

phenomenon, the researcher originally planned to investigate as many state-wide

emergency departments as possible ranging from inner city to metropolitan and

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rural/remote areas. However, on reflection and given the time frame for completion of

the dissertation, it was not only decided that the geographical area should be reduced,

but the research topic should be considerably condensed from its early objectives. Not

only was it doubtful whether an appropriate tool existed for the elicitation of the

required information but the development of such a tool would require testing before

distribution among several state-wide and possibly interstate emergency departments.

Hence the topic was condensed solely to the designing and use of a suitable tool for data

collection regarding emergency nurses who place alerts on, (or „flag‟), emergency

patients according to their own judgment of what they considered worthy of reporting

and only one hospital facility was surveyed using this tool rather than several. This

would allow for future investigation of the topic by the researcher for the elaboration of

initial findings, and modification of the research tool, if necessary, to gain data from

other state-wide and interstate emergency departments. Since triggers for „flagging‟

were under scrutiny, items such as nurse-related factors and patient-related factors for

„flagging‟, frequency and recency of „flagging‟, and nurse attitude, practice, knowledge

and perception of this practice became constructs in the proposed survey. These items

related to issues observed concerning workplace violence, nurse vulnerability and

patient care. In addition to the use of the research tool, opportunity for nurse interview

was considered to allow for elucidation of deeper meanings which nurses may ascribe to

„flagging‟. Matters relating to whether nurses use „flagging‟ as a means of protection or

retaliation against attacks of violence and/or aggression and whether nurses felt that

„flagging‟ was the only means of reporting, which emergency nurses find effective,

were to be addressed in interview questions. These matters then led to the possibility of

interview questions based on violence and aggression and reporting systems with in the

emergency department and their effectiveness. Consideration was given to the

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frequency of Code Blacks, (internal security response to threat and workplace safety),

initiated by emergency nurses as well as calls for Security staff and Police involvement.

Lastly, interview questions concerning the aftermath of violence were intended to allow

for nurses to articulate what they felt about the effects of day-to-day exposure to

workplace aggression and violence, and its influence(s) on their psychological and

physical health and health care performance. The purpose of this study was to better

understand why emergency nurses „flag‟ patients. The study specifically investigated;

Patient-related factors that impact on the „flagging‟ behavior of nurses

Nurse-related factors that impact on the „flagging‟ behavior of nurses

Attitude, practice, knowledge and perception of emergency nurses related to

„flagging‟ patients in the emergency department.

The benefits of the study included the opportunity to obtain information concerning the

phenomenon of nurse „flagging‟ and describe what exists with respect to the variables

or conditions involved in this situation in order to promote or confirm the need for

research for this chosen topic. Also, the provision of evidence on which to base further

experimental study to investigate possible causal relationships was envisioned.

1.4 Statement of the Research Question

The statement for the research question became; „Factors exist influencing emergency

nurses to electronically chart violence alerts on emergency patients.‟ The following

research question was formulated; „Why do nurses electronically chart violence alerts

on, (or „flag‟), emergency patients?‟

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1.5 Statement of the Hypothesis

According to Schneider (2003, p251), „An hypothesis is an assumptive statement about

a relationship between two or more variables that suggests an answer to the research

question‟. Both the literature review and observations made in the emergency

department involving nurse exposure to workplace violence, and nurse reporting of

violence incidence, led to the following statements which supported the hypothesis;

1. A relationship exists between nurse-related factors and the „flagging‟ behavior of

nurses. Nurse-related factors under investigation were: demographics, attitudes,

practices, knowledge, perception, frequency and recency of flagging.

2. A relationship exists between patient-related factors and „flagging‟ behaviors of

nurses. Patient-related factors under investigation were: threat to harm,

aggressive statements or threats, intimidation, clenched fists, resisting health

care, prolonged or intense glaring at nurse, name calling, yelling, increase in

volume (speech), irritability, walking back and forth to the nurses‟ area, walking

around confined areas such as waiting room or bed space, sharp or caustic retorts,

demeaning inflection, belligerence, demanding attention, humiliating remarks.

The statement of hypothesis therefore became; “Emergency nurse exposure to

workplace violence is related to feelings of vulnerability and nurse „flagging‟ of

emergency patients who exhibit or have potential for violence”.

A mixed methods approach for this research was decided upon which included a

questionnaire and focus group interviews. This would allow the researcher to probe for

a relationship between variables within a natural environment. Both quantitative and

qualitative data were to be collected from self-reported, structured questionnaires and

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semi-structured focus group interviews. To ensure that effects measured were attributed

to the independent variables, (nurse-related factors, patient-related factors, nurse

practice, attitude, knowledge and perception); questionnaire items were based on a

violence tool developed by Wilkes et al (2010). This tool was developed using the

qualitative Delphi technique, (revealing predicted cues used by nurses to report

violence). Meanings ascribed to violence by nurses were to be gained from a detailed

intensive study by Luck, Jackson & Usher (2007). Internal consistency and

reproducibility, (reliability), of items addressing the phenomenon were to be ensured by

basing the data collection instruments used on these previously designed tools and

research methods. To enhance validity, the questionnaire was piloted amongst the

proposed participant population – emergency department nurses.

1.6 Significance of the Study

An extensive literature review of articles from seven countries, (United States of

America, Canada, United Kingdom, Ireland, Turkey, China and Australia), has

indicated that emergency department workplace violence is an increasing experience for

nurses. The majority of authors cited conclude that violence in emergency departments

is continuing to escalate reaching endemic levels and inducing negative consequences

such as feelings of vulnerability and insecurity amongst nurses as well as decreased

morale and subsequent burnout and resignation (Canbaz et al 2008; Erickson &

Williams-Evans 2000; Ferns 2005b; Hegney et al 2006; Hislop & Melby 2003; Jones &

Lyneham 2000; Luck Jackson & Usher 2007; Pane 1991; Perrone 1999; Rose 1997 &

Wilkes et al 2010). In fact, 72% of nurses do not feel safe from assault in their

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workplace (International Council of Nurses 2009), and 90% experienced incidents of

physical and verbal attacks in one year in Australia alone (Jackson, Clare & Mannix

2002). All studies concede that unsafe work environments are unacceptable but despite

zero tolerance to violence being implemented in many organizations, ongoing

examination of this phenomenon is required. Relatively little is known about this

problem due to varying definitions of workplace violence, variable data collection due

to measurement of different criteria, and under-reporting of violence incidents by nurses

(Ferns 2006; Hegney et al 2006; Lyneham 2000; Perrone 1999). As a result, little is

known about some aspects concerning increasing incidents of nurse exposure to

personal violent attack and its aftermath and reasons why nurses choose to report or not

report these incidents. Reasons for under reporting revolve around what nurses ascribe

to individual acts of violence, individual desensitization to violence in the workplace,

nurses considering violence to be a part of the job, presence of mitigating and/or

contributing factors, fear of retaliation from management/superiors and lack of support

from hospital administrators (Crabb et al 2002; Howard & Gillboy 2009 & Hegney et al

2006).

The Central Northern Adelaide Health Service Prevention and Management of

Aggression Policy defines violence at work as „…any incident where a person is

abused, threatened or assaulted in situations relating to their work‟ (CNAHS Policy

Statement 2008). The policy makes provision for the reporting of incidents of violence

experienced by nurses by the use of the Report Form for Aggression and Violence. (See

Appendix 1) A total of 92 incidents were reported within a large Northern Metropolitan

Hospital by nurses using this form for the period July 2009 to June 2010 (Internal

Emergency Response Statistics 2010 & Occupational Health and Safety Risk

Management Reports 2010). These reports included 45 reports of physical abuse and 35

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reports of verbal aggression. For this same period a total of 886 Code Blacks, (Internal

security response to threat and workplace safety), were reported hospital wide involving

unmanageable serious threat to safety caused by patients. Furthermore, there were no

incident report forms used by nurses to report violence incidents for the month of June

2010 while 98 Code Blacks were instigated for the same period.

The EDIS, (Emergency Department Information System), is a readily available

electronic reporting system which emergency department nurses frequently use to

highlight patients in the emergency department who commit violent acts or exhibit

potential for violent behaviour. This electronic patient tracking system is intended to

assist nurses to identify and manage potential violence by equipping the nurse with

historic knowledge regarding such patients and thereby assisting to prevent assaults on

staff. Although no formal policy or training exists for the use of this „flagging‟ system

and no criteria exists for the basis of placing alerts on patients, (better known as

„flagging‟), „flagging‟ is perceived as a regular occurrence which nurses rely on heavily

for personal safety. However, despite this prevention method, little evaluation has been

conducted on its outcomes or on the assessment methods and motivations of nurses to

„flag‟. . This study endeavoured to better understand what triggers exist which

emergency nurses use to „flag‟ patients. Given that nursing stems from a bygone era

evolving from a basic desire to assist those in pain and suffering, (Donahue 1996), the

researcher is challenged to discover the attitudes of nurses who „flag‟ patients and the

factors that influence those attitudes. Patient-related and nurse-related factors were

systematically measured through the use of a structured questionnaire to attempt to

produce tangible analysis of the phenomenon discussed. Focus group interviews were

also held to elicit any possible underlying social prejudices which may be held by

nurses and their origins.

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1.7 Assumptions

Assumptions in this study were:

Emergency nurses are frequently faced with or exposed to violence

incidence while at work.

Emergency nurses regularly use „flagging‟ systems and violence alerts to

equip themselves against being harmed by violent patients.

Emergency nurses are influenced by particular triggers in patient behavior to

„flag‟.

The goal is to discover theories that help explain the phenomenon at hand.

1.8 Definitions of Terms and Cases

1.8.1 Violence

According to SA Health Prevention and Management of Workplace Violence and

Aggression Guidelines (2009), the following definitions of violence have been given;

(i) Workplace Violence

“An action or incident that physically or psychologically harms another person. It

includes situations where employees and other people are threatened, attacked or

physically assaulted at work.” p1.

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(ii) Workplace Aggressive Behaviour

“Incidents where individuals are abused, threatened or assaulted in circumstances

arising out of, in course of, their employment, involving an explicit or implicit

challenge to their safety, health and/or well-being.” p1.

(iii) Physical Violence

“The use of physical force against another person or group that results in physical harm.

It includes, but is not limited to, punching, biting, pushing, spitting, slapping, kicking,

beating, shooting and stabbing.”p1.

(iv) Non-physical Violence

“Such as verbal abuse, intimidating and threatening behaviour, may also significantly

affect a person's health and well-being. There does not have to be physical injury for the

violence to be a workplace hazard. Employees might be affected by workplace violence

even if they are not directly involved (for example, by witnessing an incident).”p2.

(v) Psychological Violence

“The use of power against another person or group that results in psychological harm or

an inability to develop professionally. This includes, but is not limited to, verbal abuse,

suggestive behaviour, sexual harassment, threats of physical abuse, intimidation and

bullying.” p2.

1.8.2 Victim/Perpetrator of Violence Presenting to Emergency

Cases alluding to 'victims/perpetrators of violence' possess at least one injury inflicted

by another person during interpersonal violence incidence. These presentations are

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triaged as 'reported/alleged/ suspected interpersonal violence'. In addition to this, if

these cases are detained by authorized health practitioners, Police powers or authorized

officers, (South Australian Ambulance Service), they may be categorized as

'agitation/delusion/anxiety; alcohol/drug/substance misuse; psychiatric illness;

situational crisis; social problem and/or violent/aggression behaviour. These

presentations may require treatment for mental illness and may have caused, or are at

significant risk of causing, harm to self, others and/or property.

1.8.3 ‘Flag’

A term used for highlighting a patient who exhibits, or has previously exhibited,

predictive cues for violent behaviour or who is threatening workplace safety in the

emergency department via the implementation of electronic charting for nurses using

EDIS.

1.8.4 EDIS

Emergency Department Information Service, a readily available electronic reporting

system which emergency nurses can frequently use to highlight patients in the

emergency setting who commit violent acts or exhibit potential for violent behaviour

(Bichel-Findlay, Callen & Sara 2008).

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1.8.5 Code Black

According to SA Health Prevention and Management of Workplace Violence and

Aggression Guidelines (2009, p10), 'Every health unit in SA should have appropriate

systems, procedures and resources to respond promptly and effectively when violent or

aggressive incidents occur'. Code Black is the standard internal emergency security

response to violent and/or aggressive threat to workplace safety. This code is activated

by calling #33 or activating personal duress alarms (Central Northern Adelaide Health

Service Clinical Practice Aggression Management 2010).

1.8.6 Attitude

Attitudes are social judgments involving positive or negative evaluations of objects of

thought based on cognitive, affective and behavioural components. Attitudes vary with

strength and accessibility and can be changed by the following factors; direct

instruction, operant conditioning, classical conditioning, social learning, cognitive

dissonance, unconscious motivation and rational analysis (Betsch et al 2001; Fazio &

Roskos-Ewoldson 2005 & Glasman & Albarrain 2006).

1.8.7 Trigger

According to the Concise Oxford Dictionary (1933, p1315) the definition of the word

trigger is: an event that is the cause of a particular action, process, or situation.

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1.9 Summary of the Thesis

Chapter 1 provides an introduction to the research at hand, context and significance of

the phenomenon of interest, the hypothesis and its formulation and statement of

research question. Assumptions involved in the study are listed and definitions given.

Chapter 2 begins by discussing a literature review of the aetiologies, background and

prevalence of violence and defines and describes what is revealed about this at-risk

population which presents to the emergency department for treatment of associated

violence-related injuries. This is followed by a discussion of media portrayal of

community violence and what is said about the relevance of the health care approach to

violence-related presentations. An analysis of emergency departmental policy for

regulation of violence and aggression and workplace safety, incidence and

reporting/under-reporting will follow which will compare with the experience,

perceptions, attitudes and impacts emergency nurses have regarding occupational

violence/safety. Literature examined will pertain to nurse response to violent patients

during care delivery to ascertain whether elements of stereo-typing, marginalization and

stigmatization, (as a means of self-protection), are involved and if so, if this is conveyed

within a culture of nurse consensus. This will lead to a discussion of „flagging‟, why

nurses „flag‟ violent patients and nurses' knowledge, perceptions and attitudes of

„flagging‟. Lastly, the literature review will demonstrate future implications for health

care workers in light of increasing incidence of violence in the workplace.

17

Chapter 3 will provide a discussion of the methods used for this study. It will address

the mixed methods approach used to elicit both quantitative and qualitative data and

explain the development of the research tool, (based on the Delphi technique), used to

generate this data as well the semi-structured focus group interviews. Other topics

mentioned in this chapter will be; piloting and study design, validity/rigor, internal

consistency and reproducibility of items, study setting, participant recruitment and

response rate, framework for data analysis, and ethical considerations and approval.

Chapter 4 will illustrate and describe the results of the study gained by the data

collection techniques and data analysis framework. Results will pertain to the main

points of interest:

Patient-related factors that impact on the flagging behaviors of nurses

Nurse-related factors that impact on the flagging behavior of nurses

Attitude, practice, knowledge and perception of emergency nurses related to

flagging patients in the emergency department.

Chapter 5 will provide a detailed discussion of the study findings pertaining to the main

points of interest. These will be summarized and their significance described.

Limitations/strengths of the study which are discovered will also be discussed. Finally,

possible wider, deeper impacts and/or implications which may exist in emergency

nursing culture may be addressed and recommendations given.

18

1.10 Conclusion

Current evidence shows that violence-related behaviour has a wide range of shifting

social and health-related factors and therefore is difficult to measure in reality.

Approaches to measuring rates of prevalence involve complex factors such as;

inconsistency of defining terms such as 'violence'

nurse willingness to report violence

impacts of exposure to and experience of violence on nurses

levels of policing of violence.

Limitations within literature on the prevalence of violence and its effects are produced

by insufficient statistical evidence needed to concur accurate long term historical trends

in the varied types of violence and nurse experience of violence that exist. However, a

rich body of literature is growing for the application of public health systems in the

diagnosis, treatment/rehabilitation of recently recognized factors underlying violent

activity in young males. This is evident in parliamentary discussions and formation of

diversion programs in order to decrease rates of recidivism in young offenders

(Australian Law Reform Commission 2004; Cashin 2006; Corum 2006; Henderson

2003). However, an area of concern revealed by the literature involves evidence

existing for continued marginalization of this at-risk population by nurses (Bailey 1998;

Bowel et al 2000; Heslop, Elsom & Parker 2000; Howard & Gillboy 2009 & Hegney et

al 2006). This health care approach serves to compound the alienation felt by this

population from mainstream society and exacerbates its psychosocial and physiological

effects. Further study into this phenomenon is recommended, as well as changes in

19

emergency nurse knowledge and understanding of young adolescent males who present

for treatment of wounds sustained in interpersonal violence activity.

20

CHAPTER 2: LITERATURE REVIEW

2.1 Introduction to the Literature Review

Emergency Department violence is increasingly placing emergency nurses at significant

risk of harm in the workplace ( Keely 2002; McPhaul & Lispcomb 2004; Rippon 2000).

Empirical research and data concerning this experience among emergency nurses and

the associated variables is, however, limited (Di Martino 2003; Luck, Jackson & Usher

2007). This is said to be due to the very elusiveness of the nature of violence, its varied

definitions, interpretations and applied subjectivity in perceptions (Ferns 2005b Luck,

Jackson & Usher 2007; McPhaul & Lispcomb 2004). Under-reporting of violence,

multiple reporting systems and varied methods of measuring violence all add to the

unreliability of reported rates of this difficult concept (Ferns 2005a; Gerberich et al

2004; McPhaul & Lispcomb 2004; Rippon 2000). Attempts by researchers have been

made to describe the variables which contribute to workplace violence in emergency

departments and these components are widely said to be workplace factors, personal

factors and environmental factors (Erickson & Williams-Evans 2000; Luck, Jackson &

Usher 2007; Mayhew & Chappell 2003). Since emergency departments are the first

port-of-call for community residents who require healthcare treatment/assistance, there

is an association between characteristics of community populations and violence in

21

emergency departments (Keely 2002; Kowalenko et al 2005; National Institution for

Occupational Safety and Health 2008). These factors include levels of substance abuse,

family violence, poverty, access to weapons and gang formation (Australian Institute of

Criminology 2002; Crilly et al 2004; Cunnigham & Sorenson 2007; Lyneham 2001;

Luck, Jackson & Usher 2007). Other characteristics of presenting populations said to

increase the incidence of violence in the emergency department are unemployment,

interpersonal violence and medical conditions which affect cognitive abilities

(Fernandez et al 2002; Gerberich et al 2004; May & Grubbs 2002). Studies have

demonstrated that a greater likelihood for violence in the emergency department exists

for male adolescents with history of violence (Fernandez et al 2002; Gerberich et al

2004; May & Grubbs 2002). As well as environmental factors, personal factors

attributed to emergency nurses‟ perceptions of violence and its impact and influence on

patient interaction are said to play a part in the cycle of violence within emergency

departments (Catlette 2005; Erickson & Evans-Williams 2000: May & Grubbs 2002;

Wittington & Wykes 1996). Luck, Jackson and Usher (2007), conducted a mixed

method case study on the social processes leading to the rise of aggression between

patient and nurse and the aversive stimuli involved. Distinctive behavioural components

involved in nurse-patient relationships were collectively identified as empirical

categories used by nurses to make informed risk assessment (Luck, Jackson & Usher

2007). Risk assessment is said to be a mechanism of survival among emergency nurses

generated by individual perceptions of safety and perpetuated responses to acts of

violence (Erickson & Williams-Evans 2000; Hockley 2003; Lam 2002; Levin et al

1998; Mayhew & Chappell 2003; Perrone 1999). Since consequences of emergency

department violence on nurses are both physical and psychosocial, (clinical depression,

reduced morale, poor job satisfaction and retention and increased sick leave and stress

22

leave), (Keely 2002; Mahoney 1991; Nabb 2000), it is inferred that specific cultures and

philosophies are evolving towards risk assessment amongst nurses in response to violent

patients (France & Levin 2006). Stigmatisation and exclusion of these patients is a

developing nursing culture due to daily exposure to mismanaged occupational violence

and associated outcomes of delayed post-traumatic stress disorder reaction and

cumulative trauma in nurses (Chung et al 2003; Di Martino 2003; Gerberich et al 2004;

Lanza et al 2006). This is revealed amidst a context of nurse-vulnerability and

inadequate environmental safety (Catlette 2005). Also at risk of increased vulnerability

are patients who often leave the department before assessment and treatment of their

injuries are complete, due to personal marginalization by nurses (Perrone 1999). While

a concerted effort is required to bring a shift in attitude concerning nurse reciprocity

toward violent patients, nurse risk assessment of the social constituents of violent

patients is occurring based on a poorly understood violence aetiology and misleading

public media portrayals of violent adolescent males (Blood et al 2001; Bowel et al

2000; Day et al 2004; Edgar & Rickford 2009; Indermaur 1999; MacDonald 2000;

Sanson 2000; White 2007). An issue of prevention of stereo-typing and marginalisation

by nursing staff towards violent patients who present to emergency departments now

exists. Despite what research says about violence being epidemic, there is little

scientific analysis pertaining to health workplace violence and its impact on nurses and

patient outcomes (Rippon 2000). Most published studies on emergency department

violence stem from retrospective and cross-sectional surveys and descriptive interviews.

In addition to this, perpetrator perspectives are hardly investigated due to the sensitive

nature of these issues (Kennedy 2005). However, disregarding these limitations, a

growing body of literature does exist for continued investigation in understanding the

trajectory of emergency violence, its effects and impacts and required strategies to

23

respond to this phenomenon (Chapman & Styles 2006; Distasio 2002; Gacki-Smith et al

2009). Recently Wilkes et al (2010), aimed to develop a violence assessment tool

specific to emergency department violence and nurse perceptions of violence. Having

recognized the absence of a validated tool for measuring violence indicators, and basing

the approach on previously identified behavioural components by Luck, Jackson and

Usher (2007), the quantitative Delphi technique was adopted to benefit from the

subjective judgments of nurses on a collective base (Adler & Ziglio 1996). This Delphi

technique was considered relevant in its provision of clarification of factors identified in

this literature review. This literature review pertains to examination of issues affecting

the community which are drawn into the emergency department as well as nurse

experience with violence and its effect on future behaviour.

The following topics were reviewed:

environmental factors related to emergency department violence

media portrayal of community violence

the healthcare approach to emergency department violence

impact of workplace violence on emergency nurses

implications for emergency nurses

2.2 Environmental Factors Related to Emergency Department Violence

Healthcare facilities based in communities within rates of high criminal activity,

weapons use, drug and alcohol abuse and interpersonal violence are more likely to

24

experience presentations of populations inducing acts of violence against emergency

nurses (Keely 2002 & NIOSH 2008). These patients are usually male, between the age

of 20 and 40 years and have a history of violence (Fernadez et al 2003). A review of the

literature demonstrates several studies which indicate male adolescents and associated

youth gangs are generally represented by youth who face a number of family, social and

environmental conditions which serve to inhibit their personal development and

consequently prevent their assimilation into society (Bor et al 2004; Santina & White

2000; Sercombe 2002 & White 2007). In addition to this it is revealed that social

problems such as, unemployment, poverty and decreased societal opportunities affect

the physical and psychosocial well-being of young people and that this consequently

results in an increased detriment for neighbourhood cohesion (Daly et al 2004 &

Zubrick 2006). Findings also reveal that certain factors and conditions influence violent

and aggressive, or anti-social, behaviour and that the risk of involvement in serious

criminal behaviour is proportionate to the number of these factors or conditions existing

in an offender's life over time (Sanson et al 2000 & Cashmore et al 2002). These factors

can be distal, (occurring early in life), or proximal, (occurring later in life), and as they

accumulate, so too does the risk of involvement in violent, anti-social behaviour. These

factors make up the characteristics that contribute to the precursors of aggression and

violent behaviour expressed by this particular at-risk population (Corum 2006; Day et al

2004 & Indemaur1999). Studies involving observation and patient case reports by

Martens (2004) conclude that aggression and violent behaviour is seen as a result of

social forces, or individual disposition. This implies that the external environment and

situational forces surrounding an individual, along with an individual's focus or inherent

values, may significantly influence an offender's choice to use violence or aggression in

a given circumstance. These social factors range from family environments in which

25

inadequate parenting, weak bonding between parent(s) and offspring, or parental

neglect, exist as well as implementation of harsh, inconsistent and/or abusive discipline

(Cashmore et al 2002; Daly et al 2004; Sanson et al 2000). The recently formed Ozgang

Research Network has produced findings, following systematic research into youth

gang formations, which demonstrate that family disintegration, destitution, hardship and

neediness may inevitably lead to involvement of adolescents with delinquent peers, and

victimisation. These are also considered by criminologists to be social forces indicative

of violent and aggressive behaviour (White 2002). Martens (2004), continues to add to

this rich source of literature by revealing that influential personal disposition is believed

to encompass biological make-up such as age, gender, genetics and personality, as well

as low levels of intelligence, concentration span and socio-emotional learning process.

This may be accompanied by a lack of ability to internalise dialogue, affection, thought

and/or behaviour (Cashmore et al 2002). Other major theories which are documented as

contributing to these precursors are illegal substance abuse, ready access to weapons,

social dislocation, deterioration of social morality, media influence, video games, lack

of self-constraint and chronic physical problems (Corum 2006). Findings and

conclusions from the literature consistently identified that this at-risk population is

characterised by the function of aggression and violence being a response to social

pressures. This response is perceived through the dispositional nature of the perpetrator

where decision making consists of a rationale based on beliefs, values and perspectives

considered to be less than good, logical or optimal (Zubrick 2006). The above

mentioned precursors contribute significantly to the aetiology of the relationship

between crime and mental disorder which identifies this at-risk population. A recent

article addressing these aetiologies advocates for violence offenders as patients rather

than their criminalisation (Henderson 2003).

26

2.3 Media Portrayal of Community Violence

A briefing paper addressed to the New South Wales, (NSW), Parliament by Lozusic

(2002), reveals that although the word 'gang' is not defined in the criminal law of any

Australian jurisdiction, it is used freely by the media to describe criminal or anti-social

activity by young males. In addition to this, White (2007) asserts in his research paper.

'Youth Gangs, Violence and Anti-social Behaviour', that considerable media, political

and police attention is frequently being received by gangs concerning their proliferation

and criminal and/or anti-social behaviour. Literature reveals that public acceptance of

portrayals induced by this attention causes public over-reaction and stereo-typing of

youth groups and serves to inadvertently enhance gang cohesion, facilitate its growth

and lead to increased criminal activity (Blood et al 2006; Edgar & Rick 2009;

McDonald 2000; Santina & White 2000; White 2007). Exactly how much reporting is

based on selected or excluded social statistical information recently came under scrutiny

in research involving five case studies of suicide and mental health and illness. These

cases were examined for the varying degrees of editorial control over responsible

reporting and its constituents practised by the media (Blood et al 2006). It remains

prominently obvious that studies of the relationship between media coverage of crime

and official data find news coverage of violence differs in many ways from official

statistics (Sanson et al 2000). In fact, in his paper addressing violence among young

people in Australia, Sercombe (2002), goes on to say that the media is not only

responsible for exploiting the widely misunderstood and tragic outcome of the day-to-

day violence that many young people have lived with all their lives, but it is also

responsible for sensationalising the consequential reproduction of this violence in their

personal relationships and in their relationship with society. According to Endreny

27

(1985, p242), 'Certainly the structure of journalism does not nurture, much less

mandate deliberate concern with contemplation of the scientific values governing social

science'. The media has successfully created grounds for main stream society to cast

doubt on the motivation of all groups of young people and their activity (Sanson 2000;

Santina & White 2000; White 2002). Despite the media's promotion of prejudicial

ideas, findings revealed in a paper presented at the Children and Crime: Victims and

Offenders Conference, clearly state that no dependable data-base actually exists for

statistical levels of prevalence of youth violence in Australia (Boni 1999). Despite the

questionable motivations of the media for reporting youth violence, a recent qualitative

study by the Criminology Research Council on conceptualisation and management of

fear experienced by people in relation to risk of becoming a victim of crime, reveals the

public majority accept fear of victimisation by gangs as normal. Although most

participants held cynical attitudes towards the media, 80% agreed to Australia having

become a more dangerous society (Tulloch 1998).

2.4 The Healthcare Approach to Emergency Department Violence

A global consensus in literature now exists for increasing incidence of occupational

violence in nursing – more so in emergency departments (Australian Institute of

Criminology 2002; Cooper & Swanson 2001; Gacki-Smith et al 2009; International

Council of Nurses 2005; Krug et al 2002; Leather et al 2002; Mayhew & Chappell

2001; Rumsey et al 2007; World Health Organisation 2005). Authors and resources

reviewed agree that little has been investigated regarding how nurses perceive degrees

of managerial support following incidence of exposure to and experience of workplace

28

violence. In addition to this, little is known on the effects these nurse perceptions have

on stress levels and feelings of vulnerability, job satisfaction and morale (Foley 2004;

Graycar 2003; Howard & Gilboy 2009; Keough et al 2003; Macdonald 2007). Despite

two decades of growth in research on occupational violence, which implicates the

critical necessity for associated effective organisational policy, existing policy which

addresses the rejection of tolerance to violence in the workplace, and its detrimental

effects on recruitment and retention of nurses, has done little to prevent the continuing

escalation of violence experience in emergency departments (Deans 2004; Doyal &

Dolan 2002; Holmes 2006; Keely 2002; McPhaul & Lipscomb 2004; Wand & Coulson

2006). Therefore, it is questionable if enough is being done from a managerial position

to support nurses who work in these combat zones and suffer the consequential

physiological and psychosocial scars as a result of daily occupational violence (Baillie

2005; Hislop & Melby 2003; Rosenstein 2002). Literature which discusses this issue

states that reasons for the lack of organisational support for nurses stem from historical

perspectives of violence such as 'violence being a part of the job', and interpretation of

nurse requirement for support as 'professional failure and/or incompetence' (Deans

2003; Munro 2002;). Ferns and Chojnacka (2005), go on to say that these traditional

perspectives influence nurses to tolerate violence in acceptance of this age old nursing

culture and/or attitude of subservience. Tolerance of violence is said to be evidenced by

the lack of nurse reporting of experiences of violence (Kennedy 2005; Luck, Jackson &

Usher 2006; Mayhew & Chappell 2001; Merfield 2003; Munro 2002; New South Wales

Nurses' Association 2010). Ferns and Chojnacka (2005), warn that despite the various

reasons why nurses fail to report violence-related incidents, failure to do so enhances

danger. There is suspicion that the challenge to report is not being met by nurses as a

result of traditional influences which hold nursing to ransom, keeping it underpowered

29

and preventing it from reaching the professional status it deserves (Farrell 2001; Ferns

& Chojnacka 2005; Palvianen et al 2003). In fact, Stearly (1997), states that nurses

suffer low self-esteem and act as an oppressed population which does not value itself

enough to warrant reporting of verbal and physical aggressive and violent abuse. In

addition to this the public expects nurses who work within healthcare environments to

be compassionate and caring and to therefore not retaliate against patients and their

negative behaviour. Nurses also have a tendency to live up to this expectation and put

the needs and care of the patient before their own (Celik & Bayrakter 2004; Percival

2001). Amidst this cycle of oppression and maltreatment towards nurses, and adding to

the stress-related vulnerability to violence-related trauma experienced by nurses, is the

punitive response from administrative powers to nurse complaints of violence. In fact,

an associated casting of blame on the nurse for the occurrence of violence-related

incidents about which they complain exists (Greco et al 2006; Lyneham 2001; Schriver

et al 2003; Stockowski 2010; Stordeur et al 2001). This remedial-lacking activity serves

to add to the injury to nursing staff and further decreases their self-worth. It also reduces

their opportunity for healthy recovery and sustainment of resilience causing burnout

(Lam 2002; Naismith 2000). In spite of barriers to nurse reporting such as, 'fear of

blame', 'managerial retaliation', 'poor performance review' and 'punitive response',

(Massachusetts Nurses Association 2008), nurse managers do have a responsibility to

provide a safe working environment (Alexander et al 2004; Armstrong 2002; Holmes

2006; Howard & Gilboy 2009; Keely 2002; Wand & Coulson 2006). This is

recommended by Occupational Safety and Health Association guidelines and the

Australian Nursing Federation (ANF 2005; Cartlette 2005; International Labour Office

2002, International Council of Nurses 2002, World Health Organisation 2002, Public

Services International 2002). There is strong expectation for management to engage in

30

the standards set within these policies and to ensure that strategies are implemented to

control risk and prevent violence (Australasian College for Emergency Medicine 2004;

Kennedy 2005; Occupational Health and Safety Act 2004). Methods of control of

violence, such as physical and chemical restraint and seclusion, are being built upon by

de-escalation techniques, staff training and departmental supply of security and police.

Anti-violence committees and task forces have been formed to audit violence and

inform management of its prevalence and need for intervention response agendas (Carr

Smyth 2010; Fulde 2005). Also, a zero tolerance to violence policy is not only

mandated in healthcare facilities but now adopted by Federal Executive (Australian

Nurses Federation 2005). This enforces the obligation of nurse managers to further

commit to policy review and change which attempts to reduce barriers to high rates of

occupational violence and encourage nurse reporting (Gacki-Smith et al 2009;

Stokowski 2010). However, despite these imperative institutional initiatives, the

epidemic of violence and its effects on nurses has now developed to such extent that

the need for Federal and State laws to protect nurses from violence and impose penalties

on offenders is now required (International Council of Nurses 2009; McPhaul &

Lipscomb 2004). In his report entitled 'Violence in the Workplace', Perrone (1999),

states that Criminal Law, which regulates traditional types of violence, (homicide, rape

and robbery), does not correspond to contemporary forms of workplace violence. These

elusive forms of violence are not considered criminal and therefore have no relevance to

the Crimes Act. Under Common Law victims of violence can expect re-mediation from

employers who have a duty of care to their employees. This liability has been ratified by

Occupational Health and Safety Acts which rely on internal policy rather than

legislative jurisdiction to constrain all forms of workplace violence. However, although

assault on nurses cannot be made a felony without Federal or State laws to address this

31

issue, (Gacki-Smith 2009), some Occupational Health and Safety Regulators are

beginning to venture into non-traditional terrain. Recently The Violence Against Nurses

bill went into effect in New York which states that physical assault against a nurse is a

felony subject to a penalty of up to seven years. The success of this bill being passed

occurred after the New York Nurses Association commencing action in 2008 (Hilton

2010). Although strong commitment from management is recommended by policy for

safe working environments, it is evident that challenges now exist for nurse

organisational leaders to pursue legislative involvement at Federal and State levels in

spite of ancestral nurse management perspectives. A serious attempt to reduce violence

against nurses now requires legislative advocacy and support (Gacki-Smith et al 2009;

McPhaul & Lipscomb 2004). Furthermore, it is essential that not only nurse

management but the Government, the community and nurses no longer hold a

perception of violence as being acceptable (Chapman & Styles 2006). The question

arising from this literature review is, does the vestige of the old order of nursing play a

part in the contemporary issue of workplace violence and nurse burnout, and/or, do

recent parliamentary changes in diversion of offenders from courts to healthcare

facilities without associated legislative support for protection have a cataclysmic

negative impact on nurses?

2.5 Impact of Workplace Violence on Emergency Nurses

The cycles of violence involving perpetrators and victims of violence are, turning within

healthcare facilities involving nurses in the front-lines of emergency departments

(Glaister & Kesling 2002). World-wide research demonstrates that an injury sustained

32

by nurses in occupational violence results in both physical and psychological injury

(Aleandri & Sansoni 2006; Rippon 2000). Research also demonstrates that just as

physical disability can be life long, so can the psychological/emotional wounds (Deans

2004; Luck, Jackson & Usher 2006; Lyneham 2001). A systematic review of a twenty

year period of the literature reveals the main areas impacted by violence to be bio-

physical, emotional, cognitive and social (Needham et al 2004). In addition to these

outcomes, career paths and financial status are consequently at risk (Cooper & Swanson

2001; Hislop & Melby 2003; Luck, Jackson & Usher 2006). Performance in health care

delivery is also affected as this is dependent on mastery of the practice setting. Invasion

of this setting changes the nurse concept of the environment and competence levels

(Catlette 2005; Deans 2004; Franz et al 2010). Feeling unsafe after invasion of the

workplace by violent intruders induces feelings of vulnerability, fear and anxiety which

cause hyper-vigilance and hyper-alertness (Gacki-Smith et al 2009; Lyneham 2001,

Needham et al 2004). This in turn causes emotional burnout and decreased energy and

performance/productivity levels which can lead to depression, dependency, low morale

and insomnia due to distressing dreams (Canbez et al 2008; Howard & Gilboy 2009;

Needham et al 2004). Violence induced emotion such as fear, anxiety and anger are

known to contribute to deterioration of interpersonal relationships both at work and

home (Canbez et al 2008). Ongoing emotional upheaval, as a result of persistent

exposure to trauma-related violence exposure, often leads to varying levels of post-

traumatic stress disorder, consequential anti-socialism, and individual desensitisation as

avoidance mechanisms to repeated trauma (Camerino et al 2008; Luck, Jackson &

Usher 2006; Needham et al 2004). As exposure to assault continues, nurses are said to

become less tolerant of negative behaviour and exhibit reduced levels of empathy,

interest and generalised care for others by withdrawing themselves from patient care

33

(Bilgin 2009). As threats to personal integrity and humiliation violate self-respect and

self-confidence, nurses resort to social distancing as a means of self-empowerment at

the risk poor patient outcomes (Bilgin 2009; Glaister & Kesling 2002; Secker et al

2004). These hostile barriers are said to negatively influence patient care (Ferns 2005a).

This was revealed in a study using a developed nursing relationships scale by Ku and

Minas (2010), where items such as 'worry about aggression‟ negatively correlated with

'caring/supportive approach', 'authoritarian stance' and 'negativity'. This study

recommends ongoing exploration of the role of stigma and its influence on nursing

approaches (Ku & Minas 2010). Changes in perceptions of normalcy of the nursing

environment due to assault can indeed lead to callousness and stigmatisation of patients.

This has been known to be followed by emotions such as self-blame, shame or guilt and

resignation – especially if feelings of guilt are reinforced by nursing managers

(Newham et al 2004). Often nurses bear feelings of despair which can lead to

dependency and failure and suicidal ideation due to mismanaged occupational violence

and lack of support from policy and legislation (Jones & Lyneham 2000).

2.6 Implications for Emergency Nurses

For those nurses who stay in the nursing industry as emergency nurses and continue to

face head on the realistic outcomes of a society expressed by shifting diversities in

culture/beliefs, languages, socio-economical standards, ethics/morals, substance

use/abuse, disease, social/economic and political uncertainties, (including terrorism), the

challenge is becoming greater than the resources to meet it with (Fulde 2005;

International Council of Nurses 2009; Kennedy 2005; Mayhew & Chappell 2003;

34

Rosenberg et al 2006; Taylor & Rew 2010). Violence reflects this. Nurses are now

meeting violence with hostility in order to survive this industry of multiple, unaddressed

contemporary issues as they are forced to contend with them alone (Chapman & Styles

2006). Stigmatisation is not only a coping mechanism, but a fast becoming a standard of

nursing care (Bilgin 2009; Canbez et al 2008; Luck, Jackson & Usher 2007;

Whittington & Richter 2006). Little research has been accomplished on the knowledge,

perceptions and attitudes nurses have on violence (Catlette 2005; Ferns 2006; Fulde

2005; International Council of Nurses 2009; Kennedy 2005; Ku & Minas 2010; Munro

2002; Rippon 2000). No standard criteria defines what violence is or identifies its

attributes, signs or symptoms (Chapman & Styles 2006; Crabb et al 2002; Gacki-Smith

et al 2009; Wilkes 2010). There is no central data collection base or agreed means of

measurement for its proliferation or prevalence as it spreads throughout society (Hegney

et al 2006). Nurses suffer threat, shame, judgement and inhibition while under attack

(Howard & Gilboy 2009; Hislop & Melby 2003; Senuzen Ergun & Karadakovan 2005)

while amidst the suffering, reports of this battle are not forthcoming and reasons for this

are uncertain (Ferns 2006; Rippon 2000). One concept is that the construct of reporting

forms is not suitable for conveying the lived experience or contextual reality of the

violent event (Luck, Jackson & Usher 2006). Little research exists on what constitutes a

nurses decision to report or what their beliefs are on the effects of reporting (Chapman

et al 2009; Kongsuwan et al 2009; Luck, Jackson & Usher 2007). However, as long as

battle worn nurses slip away, those engaged in battle do not report,

exploration/investigation by researchers is insufficient, education/training does not

equip, nursing hierarchy remains aloof, policy is unsupportive, unions are handicapped

and government is irresponsible, nurses are left to their own devices for survival

(Aleandri & Sansoni 2006; Chapman & Styles 2006; Loke 2001; Merfield 2003).

35

2.7 Summary

This chapter has reviewed literature on the trajectory of violence in emergency

departments, its aetiology, prevalence, effects and implications. In doing so it is evident

that not only is this contemporary nursing issue significantly complex, but its multiple

facets are not identified or measured effectively. The literature has revealed that this

occurs while nurses are rapidly falling victim to violence and policy makers are slow to

intervene and consequently a subculture of withdrawal from healthcare delivery is

developing. Although nurses have resorted to marginalisation of violence-related patient

factors, and the media influences this activity, the literature review indicates a need for

further exploration into the variables associated with emergency department violence. It

is evident that the existing body of research is weighted towards descriptive studies and

empirical research is limited (Fernandez et al 2002). However, the distinct behavioural

cues for patient-related violence identified in the mixed methods case study by Luck,

Jackson and Usher (2007), are elicited to a greater extent from nurses by the application

Delphi technique used by Wilkes et al (2010), in the endeavour to produce a violence

tool for measurement. This method yields subjective judgments of individuals on a

collective basis allowing for quantitative analysis and interpretation of data (Adler &

Ziglio 1996). The enquiry into nurses' perceptions of violence and its impact on their

attitudes in this empirical study could assist in understanding how nurses are best

facilitated in their challenge to address occupational violence. The following chapter

describes the methodology used to conduct this study.

36

CHAPTER 3: METHODOLOGY AND METHODS

3.1 Introduction

An empirical and analytical research approach based on a positivist paradigm helps to

clarify, govern, support and recommend knowledge in the discipline of nursing. This

research can contribute to the improvement of nursing care, patient outcomes and cost

effective, efficient practice (Burns & Grove 2007). This research permits the questions

that arise from daily nursing practice to be answered and can yield new nursing

knowledge which in turn generates appropriate nursing services (Caldwell 1997). This

chapter describes the mixed methods approach used in this study to explore the

variables of nurse-related factors, patient-related factors and nurse knowledge, attitudes,

practices and perceptions of „flagging‟ violent patients in the emergency department. A

description of the research design relating to the underlying paradigms is given. As well

as this, the study population, inclusion and exclusion criteria, recruitment strategies and

the study setting are described.

All researchers have different beliefs and ways of viewing and interacting within their

surroundings. As a result, the ways in which research studies are conducted vary (Polit

& Beck 2008). However, there are certain standards and rules that guide a researcher‟s

actions and beliefs. Such standards or principles can be referred to as a paradigm (Polit

37

& Beck 2008). To gain a better understanding of why and how the researcher chose the

methodological approach in this study the aim of this chapter is to;

1. discuss the paradigm that best fits the focus of this study

2. discuss the research design and methodology utilised in this study

3. discuss the study and data collection activities

4. discuss analysis methods.

3.2 Research Paradigm for this Study

A paradigm is a template produced by a theory held by a researcher. This template is the

frame for the research process based upon the patterns of perceptions and beliefs held

by the inquirer (Weaver & Olsen 2006). To clarify the formation of inquiry and

methodological choices regulating this research, the paradigm adopted for this study is

initially discussed.

Nursing practice involves facilitation of extensive multiple and varied patient

requirements which are carried out in a manner of sustained objectivity based on a

neutral stance (Weaver & Olsen 2006). Therefore, a mixed methodology was necessary

to address this diversity and complexity of practice taking place within an environment

of violence. A quantitative methodology stems from the positivist philosophy. However,

positivists argue that only one objective reality exists (Weaver & Olson 2006). The

researcher believed this perspective to be unsuitable as it did not allow for the

investigation of the many truths and multiple realities associated with emergency nurse

experiences under investigation in this study. Hence, the researcher decided to

38

incorporate qualitative methodologies into the research design as well as quantitative

methodologies to permit investigation of the many variables concerned with this

research. Therefore, this study utilised a mixed method approach to explore reasons why

nurses „flag‟ violent patients. The use of both qualitative and quantitative

methodologies was necessary to encompass the different aspects of nursing approach to

care of violent patients. This type of paradigm sanctions the all-inclusive perspective of

the emergency nurse and violent environment (Weaver & Olson 2006). Furthermore,

the interpretive paradigm, which provides an opportunity for individual expression of

research participants, (Weaver & Olson 2006), was also considered by the researcher to

enable satisfactory capture of the observed complex nature of the phenomenon. In the

end, a template of combined quantitative/positivist with the qualitative/interpretive

paradigms was chosen for this study. This combination of paradigms would give the

researcher the ability to statistically analyse the scientific data while also recognizing

the complex psychosocial and emotional factors that influence nurse „flagging‟

behaviour. The discussion that follows elaborates and describes how each paradigm and

methodological approach was implemented in this study.

3.3 Research Design and Methodology

In this mixed methods study, quantitative, (self-reported questionnaires), and

qualitative, (semi-structured focus groups) data collection techniques were used.

Questionnaire items in the form of structured and multi-faceted multiple choice

questions, Likert-Scale questions and open-ended free text questions were used to

collect data in this study. In addition, qualitative research in the form of participant

focus group interviews was used. According to Morse and Richards (2002), qualitative

39

descriptive approaches ensure that evidence of experience and knowledge are acquired

when quantitative methods are used. Qualitative open-ended questions allow individual

participants the opportunity to disclose their perceptions and knowledge (Morse &

Richards 2002). As qualitative descriptive research assists with emphasizing the

existence and extent of issues, and may lead to recommendations which induce policy

change, interviewing emergency nurses who work in patient-related violence fields, was

considered to give a deeper understanding of the current issues and experiences

associated with provision of nursing care to violent patients (Taylor, Kermode &

Roberts 2007).

3.4 Research Tool Development

No previously tested questionnaire was available for this research study. Therefore, the

researcher was required to develop and validate the questionnaire before use. The

research instrument was constructed after a thorough review of the available published

literature, and observations supporting the phenomenon under investigation. The

researcher was confronted with two major issues when developing the questionnaire.

Firstly, a tool needed to be developed that would accurately assess the variables under

investigation, and secondly, the researcher needed it to be consistent when used on

various levels of nurses with different demographic backgrounds. These two

characteristics of a measurement tool, (validity and reliability), needed to be explored

before use (DeVaus 2002 & Schneider et al 2003). How the researcher addressed the

issues of validity and reliability during the questionnaire development will be explored

below.

40

Luck, Jackson and Usher (2007), in a study of emergency department workplace

violence entitled „STAMP: components of observable behaviour that indicate potential

for patient violence in emergency departments‟, identified five predictive cues used by

the nurses for the evaluation of potential patient-related violence. These cues formed

the acronym „STAMP‟. According to Luck, Jackson and Usher (2007, p14), „The five

interrelated components of STAMP are: staring and eye contact, tone and volume of

voice, anxiety, mumbling and pacing‟. These identified empirical factors mirrored

earlier studies of methods for violence detection used by nurses, (Mayhew & Chappell

2001). Not only did this study identify these empirical components, but it also explored

the psychological responses of nurses ascribed to potential violence and violence

incidents at work. Hence, meaning was conveyed to nurse response to violence. These

cues also contributed to the evidence-based establishment of a tool for the assessment of

nurse perception of causes and/or indicators for violence by Wilkes et al (2010). Wilkes

et al (2010), used the Delphi technique and these cues for an evidence-base framework

for the assistance of their study. Initially the five predictive cues were used to create a

37 item assessment tool. The Delphi technique is defined as a set of procedures for the

elicitation and refinement of the opinions of an expert group (Dalkey 1967). Outcomes

of this elicitation of collective, subjective opinions/judgments are said to be objective

(Johnson & King 1988), since it allows the expert group as a whole to address a

complex phenomenon. This statistical combination of group responses allows for a

quantitative analysis and interpretation of all group participants (Rowe & Wright 1999).

This is best used when deeper knowledge about an observed issue or phenomena is

sought (Adler & Ziglio 1996). In round two of the Delphi technique based on the survey

by Wilkes et al (2010), the initial 37 cues, (based on the five identified cues from Luck,

Jackson and Usher (2007)), were reduced to 28 cues and round three reduced these cues

41

to a 17-item violence specific tool for the nurse prediction of potential patient-related

violence. These two studies were used as a framework for the development of the

research tool used for this study‟s examination of why nurses „flag‟ emergency patients.

Data pertaining to nurse demographics, patient-related and nurse-related factors of

„flagging‟, and nurse practice, knowledge and perception of „flagging‟ were collected in

the form of structured and multi-faceted multiple choice questions, Likert-scale

questions and open-ended free text questions (See Appendix 2: Research

Questionnaire). Semi-structured interviews were also incorporated into the study design

to investigate and describe current emergency nurse practices of „flagging‟ violent

patients. (See Appendix 3: Focus Group Interview Questions). Nurses who were

actively practicing in the emergency department setting were therefore invited to

participate in focus group interviews to elicit experiences about why they „flagged‟

patients. The use of the developed research tool and the establishment of focus group

interviews were considered ideal for revealing the complexities experienced by nurses

as they interact with violent patients within their work environment.

3.5 Study Setting/Research Site

Overall, the participating hospital provided a range of characteristics and services that

offered the opportunity for this study to encounter numerous nurse-„flagging‟/patient-

related violence issues. Some of the features of the hospital included 151 general bed

facility, located to the north of Adelaide in South Australia. The hospital serves as a

catchments area for a large community consisting of various levels of low socio-

economic populations and sees greater than 54 000 presentations through its emergency

doors per year. The rate of presentations is reported to increase yearly by 5-6%. (News

42

Review Messenger 2011). This facility often transfers critical patients to a larger, more

specialized tertiary inner city hospital. The emergency department currently employs

approximately 159 nurses amidst a background of dynamic rates of retention and

recruitment. Since the month of July in 2005, there has been a steady increase of code

black incidents within this facility ranging from 30 in July 2005 to 148 in July 2010.

(See Appendix 4: ED Violence Incidents Data). There is an average of 32 violent

incidents per week at this emergency department (ABC News 2011). The most common

causes for code blacks are patient detainment, altered perception and need to provide a

safe environment, followed by high risk behaviour, psychosis and unrealistic

expectations. (See Appendix 4: ED Violence Incidents Data). Rates of submission of

violence and aggression incidents reports by nurses in this facility greatly differ from

the actual number of recorded code blacks which take place for the same periods. (See

Appendix 4: ED Violence Incidents Data). In addition to these characteristics, are issues

of overcrowding and under resourcing due to the increasing population within the

surrounding region and communities which add to nurse experiences of increased stress

levels, burn-out, low morale and fear of violence (The Advertiser 2011). These issues

have been cited in various local and major newspapers on a regular, ongoing basis.

Articles from the newspapers depict, (although possibly with exaggeration), concerned

medical and nursing organizations attempting to lobby politicians within the

Department of Health concerning escalating violence in the workplace as the population

grows and demands and waiting periods increase (See Appendix 5: Articles). The

emergency department is known to run at a 130% capacity most days and holds 60-80

patients while being planned and staffed for a maximum of 48 patients (891 ABC

Adelaide). Therefore, nurse-„flagging‟/patient-related violence issues, which are central

themes within this study, had a significant relevance within this facility. The facility

43

expressed a willingness to participate in the research study. (See Appendix 11: CNHAS

Ethics Approval & Hospital Setting Willingness to Support).

3.6 Study Population

A purposeful sample was recruited in this mixed methods study. The sample included

emergency nurses from the research setting described above. The accessible population

included 150 nurses working full time, part time and casual.

3.7 Inclusion/Exclusion Criteria

The study inclusion criteria are listed below:

1. Registered and Enrolled Nurses holding a current licence with the Australian

Health Practitioners Registration Association.

2. All nurses working in the department at the time of the study who are employees

of the organization are included as potential participants.

3. Nurses working full/part time or casual (at least two shifts per week) in the

emergency department

4. Nurses between the age of 20-65 years, (since entry level for nursing is greater

than 20 years and no one over the age of 65 years was employed in the

emergency department).

5. Nurses with a minimum of six months experience in emergency nursing. The

researcher believed that the pressures that accompany being a new employee

were not an ideal or stable background in which to commence this research

project.

44

The inclusion criteria were established to increase the chances of obtaining enough data

for each participant and to minimise the extent of variation between participant

populations (Polit & Beck 2008). For example, inclusion criteria (2) stated that nurses

needed to be regular hospital employees and inclusion criteria (3) stated that participants

had to work at least to two shifts per week in the ED. The researcher believed that

unless the employee worked a minimum amount of shifts that the chances of collecting

enough data would be severely compromised. Since casual employees do not have

regular rostered shifts there was doubt as to how much data would be available during

data collection.

The study exclusion criteria were:

1. Agency nurses who work from time to time in the department.

2. Graduate Program nurses.

3. Nurses that work less than two shifts per week.

Emergency nurses with varied experiences, background and academic and career

achievement were included. All participants were free to withdraw their participation

at any time without prejudice. Out of the 159 nurses who were approached 85 nurses

(53.4%) participated in the study and of those participants, 27 nurses (31.7%) consented

to participate in the focus group interviews. All nurses who participated in the study met

the inclusion criteria. Out of the 159 nurses who were approached, 26 were on annual

leave at the time.

45

3.8 Recruitment Strategies

Announcement of the study was advertised throughout the emergency department via

flyers posted on staff noticeboards one week prior to the introduction of the research

survey. Recruitment lectures were arranged with the permission of the ED nurse

manager. Recruitment was from the investigator‟s workplace where afternoon nursing

handover was used as a recruitment session in which to introduce the study and

distribute questionnaires. The allocated time for the research recruitment presentations

was 45 minutes. These sessions were arranged and conducted similarly to the

educational activities that occurred for ED nurses. All attendants at these sessions, (14

sessions in total over a two week period), were recorded and non-attendees received

questionnaires via internal department mailing system. During these sessions the

purpose of the study, procedures involved, time of commencement and duration were

explained. Any questions raised by personnel during these sessions were addressed

immediately by the investigator. To maintain consistency, all of the recruitment lectures

were presented by the researcher. (See Appendix 6: Advertisement for Survey

Participant Recruitment). Recruitment for structured interviews was explained in the

handover sessions. A „Willingness to Participate in Focus Group Interviews Form‟ was

included in the questionnaire. Interested personnel were invited to fill in this form,

detach it from the questionnaire and submit their names and contact details to the

questionnaire collection box prior to the end of the survey period. (See Appendix 7:

Willingness to Participate in Focus Group Interviews). A Participant Information Sheet

was included in the questionnaire containing the chief investigators contact details. (See

Appendix 8: Participant Information Sheet). Potential participants had two weeks to

decide whether to take part in the study giving adequate opportunity for them to discuss

46

the proposed survey with their peers and the researcher. Reminder notices were also

issued distributed around the ED prior to completion of the survey period.

Questionnaire response rate was enhanced by design consisting of simplicity, regularity

and symmetry (Fanning 2005).

3.9 Ethics Approval

One of the most important aspects of research is to protect participants from harm. The

type of ethical issues encountered in qualitative and quantitative research may

sometimes differ considerably. Therefore, a variety of ethical and legal issues must be

considered before commencing research which includes human subjects (Schneider et

al, 2003; DeVaus, 2002; NHMRC, 2006). Across Australia, the National Health and

Medical Research Council (NHMRC) is the national organisation that provides support,

advice, and develops regulations about health and human research ethics in Australia

(Australian Government 2007). For this study, the researcher used such guidelines as a

primary source for highlighting issues in this study. The specific ethical issues relevant

to protecting research participants throughout this research project included;

Voluntary participation/informed consent

Risk/beneficence of participants

Anonymity.

All of these topics will be discussed below.

47

3.10 Approval from the Ethics Committee

This research study was examined by members of the Research Committee of the

University of Adelaide, South Australia after submitting a research proposal. (See

Appendix 9: Research Proposal). There was one concern raised by the University of

Adelaide Ethics Committee members surrounding the issue of participant‟s ability to

seek counselling in the event of becoming distressed while participating in the survey

and interviews. This concern delayed the initial time set for the survey period. In

response to this concern the researcher was able to reiterate that access to hospital

debriefing and counselling measures was clearly set out on the participation information

sheet. The Ethics Committee members were satisfied with all aspects of this proposal

and approval was granted on the 6th

June 2011. (See Appendix 10: University of

Adelaide Ethics Approval). In addition to this research approval, proposal for this

research was submitted to the participating hospital‟s Ethics Committee and granted.

(See Appendix 11: Central Northern Adelaide Health Service Ethics Approval).

48

3.11 Voluntary Participation/Informed Consent

In order for participants to make a true choice of whether to participate in any study,

individuals require accurate information (DeVaus 2002). All potential participants were

informed about the range of matters relating to the research study they were to consider

being involved in before giving consent. (Schneider et al 2003). To provide potential

participants with accurate information about the study, an information sheet was

developed (See Appendix 8: Participant Information Sheet). This information sheet

detailed criteria such as; purpose and possible benefits of the study, assurance of

confidentiality and contact details of chief investigators and Human Ethics Committee

Secretary and CNAHS committee members for complaints or raising of related issues.

Also information was given concerning accessibility of counselling and bereavement

services available within the health facility. No coercion or persuasion was used to

recruit participants. Participant anonymity and confidentiality was secured during

survey administration and collection and piloting. A clearly labelled, locked collection

box was placed in the staff tearoom for the return of questionnaires. The collection box

was personally collected by the researcher at the close of the three week period.

Individual completion and submission of the questionnaire was considered as implied

consent of the participant. Immediately after the closing of the questionnaire period,

focus group interviews were held over the next two weeks in a secluded tutorial room

during the usual allocated time for staff education, (60 minutes). Questions were open-

ended, clearly formulated and neutral so that their formation does not influence the

answer, and carefully sequenced. (See Appendix 3: Focus Group Interview Questions).

Data collection from interviews occurred via digital audio recording. This method can

obtain verbal information verbatim. To protect the confidentiality and anonymity of

49

respondents, particular care was taken to ensure questions did not reveal the identity of

individuals. Each of the focus groups contained four participants. Participants, who

were already aware of the upcoming interviews via research introductory sessions held

in nursing handovers, were invited to nominate themselves for interview by completing

and returning the appropriate willingness form attached to the questionnaire. In the

event of no one nominating themselves reminders for recruitment were prepared.

Nominees were notified of the proposed date and time of the interview sessions by the

researcher and their availability discussed. All nominees who participated in the

interviews received a consent form to sign attached to a participant information sheet.

(See Appendix 7: Consent to Participate in Focus Group Interviews and Associated

Information Sheet).

3.12 Risk/Beneficence of Participants

According to Minichiello et al (1999), risk is considered to be something that may pose

as a potential harm to participants. Such harm may include injury, emotional distress,

loss of self-esteem, or embarrassment. Therefore, it is essential to ensure that the risk

research participants take when agreeing to partake in a research study never exceeds

the potential of humanitarian benefits of the knowledge to be gained (Pilot, Beck &

Hungler 2001). In this study there were three main types of data collected that included

personal details about the research participants; personal interview responses and

participant responses from the questionnaire. Although some demographic data was

collected from all participants, none of the participants could be identified from such

information. Therefore, data collected in this manner was seen as having a minimal risk

50

(Pilot, Beck & Hunger 2001; Taylor, Kermode & Roberts 2007). Another potential risk

was the possibility of participants becoming stressed and upset related to conveying

experience of exposure to patient-related violence. The researcher did not want the

participants to feel isolated or insecure about any of the research details. Therefore, the

researcher provided an opportunity to facilitate all participants in case they wanted to

discuss any concerns or uncertainties they had. The researcher provided her contact

phone number that all participants could access 24 hour/7day a week if they required.

3.13 Confidentiality/Privacy

Every attempt was made to keep all research data private and confidential. No nurse

participant names were documented on the questionnaires. Nurse participants were

identified only by a code number. The code list was maintained by the researcher and

kept securely stored. The Government‟s policy „Australian Code for the Responsible

Conduct of Research‟, (formally adopted by the University of Adelaide), stipulates

specific guidelines that address issues such as; data storage, authorship, publications,

conflict of interest, ethics clearance, and research misconduct. This policy specifies the

minimum period of time the researcher must retain data, persons who should have

access to confidential data, and where, how, and by whom confidential data must be

stored (Australian Government 2007). Any reference to participants during the taped

interviews was not transcribed from the audiotapes nor used in the final data analysis.

References to the participants in the results chapter were made as pseudonyms.

51

3.14 Security of Data

All of the written data will be destroyed in accordance with University of Adelaide‟s

Conduct for Research Policy requirements. The audio-taped interviews were erased

once data analysis was completed and the associated chapter was finalized. The only

persons who had access to the research data was the researcher and her research

supervisors. No copies of the audio tapes or corresponding transcripts were made.

3.15 Data Gathering Instruments and Procedures

In this study, data was collected from two activities. The two primary data sources

included the survey questionnaire and focus group interviews. The tool development

and the general methodological process for each activity will be discussed under the

specific headings below.

3.15.1 Issues of Validity and Reliability

(i) Validity

Validity is the most fundamental consideration in tool development and refers to the

degree that the instrument measures what it claims to measure (DeVaus 2002). There

are three basic ways in which to assess the validity of an instrument; criterion, content

and construct validity. The criterion validity approach compares the new tool to an

existing well-accepted tool that measures the same concept (DeVaus 2002; Schneider, et

al 2003). Other instruments were found in the published literature - namely Wilkes et al

(2010) and Luck, Jackson and Usher (2007), (as discussed earlier), which assisted to

52

test the rigor of this instrument. Consideration was also given to the issue of content

validity. Content validity refers to the ability of the instrument‟s items to represent the

content of the given construct (DeVaus 2002; Schneider et al 2003). To tackle the issues

of content validity, the researcher reviewed literature on completed studies by well-

established research experts to compare the questionnaire‟s content. The researcher

wanted to ensure that the tool focused on fundamental and essential nurse „flagging‟

concepts (DeVaus 2002; Schneider et al 2003). The language and sentence structure of

every question was examined carefully so that the participants would not be confused

by the content of the questions. The last type of validity that required discussion is

construct validity. Construct validity refers to the extent in which the instrument

measures a theoretical trait (DeVaus 2002; Schneider et al 2003). This type of validity is

difficult to achieve and was not used in this study as there was no single, well

established theory associated with nurse „flagging‟ suitable for this study.

(ii) Reliability

As well as the issue of validity, it was essential to consider the reliability of the

questionnaire. Reliability addresses the ability of a measuring tool to provide the same

result on repeated occasions (DeVaus 2002; Schneider, et al. 2003). The method of test-

retest reliability addresses the question of consistent answers from multiple occasions of

use. DeVaus (2002), suggests that a trial of the instrument be undertaken on a smaller

but similar practice sample to that being used in the study. To address the issue of

questionnaire reliability in this study, pilot testing was used. Twelve experienced

emergency nurses were asked to complete a pilot questionnaire. Eleven nurses

completed and submitted the questionnaire. (See Appendix 12: Pilot Questionnaire).

The answers from the pilot questionnaire were evaluated and the tool assessed for

53

consistency and reliability of questions. Results indicated that the questionnaire was a

reliable tool. The final content of the questionnaire included short answer and tick box

response questions as well as a demographic questionnaire section (see Appendix 2:

Research Questionnaire)). The researcher developed the questionnaire by selecting

information that was considered fundamental to nurse experience of patient-related

violence knowledge. The questions were designed to target and explore emergency

nurse knowledge, attitude and practice relating to „flagging‟ violent patients. In addition

to the questionnaire data, the researcher reviewed policy and procedure manuals located

at the hospital research setting. (See Appendix 13: Hospital Policy). This information

was used to assist the researcher during the development of the questionnaire.

3.15.2 Review

The Occupational Health and Safety policy for the study was reviewed by the

researcher. This included guidelines for nurses to follow when confronted with violent

patients. Information from these policies needed to be considered before finalising

participant questionnaires and preparation for focus group interviews. The rationale

behind this review was to assess the areas of occupational violence and aggression that

had already been addressed by hospital policy and whether or not a policy for the

practice of „flagging‟ existed

3.15.3 Focus Group Interview Guides

Interviews completed during this study involved three groups of four participants of

various nurse classifications. To maintain consistency, all of the interviews were

conducted by the researcher. One set of interview questions was developed for all

groups of participants (see Appendix 3: Focus Group Interview Questions). The open-

54

ended questions used during the interview process were based on recommendations

from existing literature and conversations with the emergency nursing staff. The use of

the same questions for each group and the use of a single interviewer was thought to

increase the reliability of the data collected (Fazzone et al 2000). Fazzone et al. (2000)

found that the multiple perspectives gathered during focus groups provided insight into

the consistency and accuracy of data. The reason for the inclusion of the focus groups

was to enable further evaluation of nurse „flagging‟ of violent patients. The open ended

semi-structured questions utilised during the focus group discussions centred on

discovering what the nurses‟ perceptions were regarding their experience of flagging

violent patients during their daily nursing practices. In addition, the researcher was also

interested in discovering if participants‟ believed they gained any benefit or practical

assistance from the practice of „flagging‟. Responses could reveal the need for any

changes in management of violent patients, reporting methods, or nursing education

which may benefit future care for emergency department violent patients and nurses.

3.15.4 Statistical Analysis

Demographic items in the questionnaire tool in section A search for data presenting

with categorical characteristics such as „age‟ and „gender‟, „overseas trained‟, and „

Time in emergency field‟. Categories such as these do not allow for mathematical

manipulation and are assigned symbols revealing percentages, ranges, frequencies and

modes (Schneider 2003). Other questionnaire items, as in sections B and C of the

questionnaire, search for data concerning choices representing a „…relative ranking of

attributes levels‟ (Pilot & Beck 2008, p.557), where measurement relies on the

participant‟s subjective opinion of „less‟ or „more‟ and is revealed in percentages,

ranges and frequencies from modes and medians while absolute zero doesn‟t exist

55

(Schneider 2003). The data collection tool for this study uses two types of measurement

in research, namely; nominal and ordinal. (See Appendix 2: Research Questionnaire).

These data results will be discussed and presented in tables and figures in the next

chapter, Chapter 4 the results chapter.

3.15.5 Thematic Analysis

For this study, thematic analysis allowed the researcher to report the experiences of the

study participants which were captured during the interview process. Thematic analysis

is a method for „…identifying, analysing and reporting patterns (themes) within data‟

(Braun & Clarke 2006, p 79). Thematic analysis is thought by many to be a useful

method to analyse qualitative data and provide rich, detailed, and complex accounts of

data (Fereday & Muir-Cochrane 2006; Braun & Clarke 2006). Thematic analysis is an

effective analysis method for interview data as it does not rely on a theoretical

framework (Tuckett 2005; Braun and Clarke 2006). Therefore, the researcher believed

that its use in this study would be suitable and beneficial. A detailed discussion in

Chapter 4 will describe how the researcher applied this analysis process to the study

data.

3.16 Conclusion

This chapter began with a description of the research paradigms which guided the study

methodology. Following the discussion about the research paradigms, a detailed

description of the research design and methods was shown to support the researcher‟s

choice of sampling, data collection and analysis. Ethical issues such as voluntary

56

participation, consent, risk, privacy and confidentiality, and security of data were

addressed in detail.

There were only two published studies that could be found that clearly identified nurse

„flagging‟ related categories (Luck, Jackson & Usher 2007 & Wilkes et al 2010). The

process of evaluation of the phenomenon was assisted by both qualitative and

quantitative data collected. There will be an in-depth discussion in Chapter 5 regarding

the outcomes of the utilization of Luck, Jackson and Usher (2007) and (Wilkes et al

(2010) studies which identified 17 cues/categories nurses use for identifying patient-

related violence. The next chapter will reveal quantitative and qualitative results from

the survey questionnaire and focus group interviews.

57

CHAPTER 4: RESULTS

4.1 Introduction

This chapter will provide a detailed description of participant‟s demographics and the

analysis of qualitative and quantitative data collected during this study. There were two

data sets collected to address the study objectives (1) the questionnaire and (2) the focus

group interviews. Raw data from the questionnaire was summarised in tables and graphs

using descriptive statistics and chi-square tests. Nominal and ordinal data was captured

in Section A relating to nurse-related factors and nominal data was captured using

ranking of items in Section B, C and D. Qualitative data captured from the focus group

interviews and open-ended items in the questionnaire were analysed thematically into

sub-categories and major themes.

4.2 Study Sample

At the time of the study, there were 159 nurses working in the emergency department,

26 of whom were on leave. Out of the 133 nurses who were present at the time of the

study and approached for recruitment, eight nurses were Duty Nurse Coordinators.

These nurses took charge of all issues raised in the emergency department in the

absence of Executive staff and attended all departmental issues raised involving

58

complaint, disaster, conflict, risk to safety and code blacks and were therefore included

in the study. Junior Registered Nurses differed from Senior Emergency Nurses in that

they were classified as Level 1 RN‟s while Senior Emergency Nurses were classified as

Level 2 RN‟s and acted in level 3 positions in the absence of Level 3 RNs (Clinical

Service Coordinators and Duty Nurse Coordinators). A total of eighty five (n=85),

emergency nurses participated in the survey giving a response rate of 63.9%. The

response rate for Enrolled Nurses was 87.0%, for Junior Registered Nurses was 67.0%

and for Senior Registered Nurses was 27.30%. Less than a third of the senior Registered

Nurses responded to the survey. (See Table 1 below: Response Rate by Emergency

Nurse Classification).

Table 1 Response Rate by Emergency Nurse Classification

Nurse Classification Total

employed On Leave Present Responses %

Enrolled Nurse 25 2 23 20 87.0%

Junior Registered Nurse 105 17 88 59 67.0%

Senior Registered Nurse 29 7 22 6 27.3%

Total 159 26 133 85 63.9%

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4.3 Section A1 Emergency Nurse Participant Demographics

Table 2 below provides an overview of the demographics of the emergency nurse

participants. The mode age class was 41-50 years (31.8%) with 28.2% aged 31-40

years. Eighty per cent of the sample was female. Nearly a quarter of the sample (23.5%)

were Enrolled Nurses, two thirds (69.3%) were junior Registered Nurses and a third

were senior Registered Nurses. The majority of nurses (38.8%) had been in their current

position for two to five years. Similarly, the majority of the nurses (36.5%) had been in

the emergency field for three to five years. Most nurses (35.3%) had been in the current

location for up to two years. There were no Aboriginal or Torres Strait Islander descent

nurses and 7.0% of nurses were overseas trained. The mode shifts worked were part-

time permanent (51.7%), all shifts (77.6%) and seven day roster (93%). The highest

qualification held was a Master‟s degree (3.5%), followed by a Post a Graduate

Diploma (17.6%). Most nurses (41%) had achieved a Bachelor of Nursing. The majority

of nurses (76.4%) were not studying at the time of the study and of those who were,

17.6% were studying a Post Graduate Diploma.

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Table 2 Demographic Summary of 85 Emergency Nurses including Age, Gender and Career

Experience

Variables Categories n % Variables Categories n %

Age Aboriginal or

Torres Strait Is

21-30 23 27 Yes 0 0

31-40 24 28.2 No 85 100

41-50 27 31.8 Overseas Trained

51-60 11 12.9 Yes 6 7

Gender No 79 93

Male 17 20 Work Status

Female 68 80 Full time perm 34 40

Current Position Part time perm 44 51.7

EN 3 3.5 Casual 7 8.2

EN Diploma 12 14.1 Shifts Worked

EN Ad Diploma 5 5.9 All Shifts 66 77.6

RN L1 37 43.5 Day Shifts 7 8.2

RN L2 7 8.2 Night Shifts 10 11.8

RN L3 15 17.6 Rostering

ACSC 3 3.5 7 Day Roster 79 93

DNC 2 2.3 Mon-Fri 3 3.5

NP 1 1.2 Weekends Only 3 3.5

Time Current Position Highest Qualification

< 6 months 7 8.2 EN Certificate 2 2.3

6-12 months 6 7 EN Diploma 12 14

12-18 months 9 10.6 Advanced Dip EN 6 7

2-5 years 33 38.8 Nursing Degree 35 41

6-10 years 18 21.2 Post Grad Cert 12 14

> 10 years 12 14 Post Grad Dip 15 17.6

Time in Emergency Field Masters 3 3.5

0-2 years 25 29.4 Currently Studying

3-5 years 31 36.5 Yes 20 23.5

6-10 years 21 24.7 No 65 76.4

> 10 years 8 9.4 Level of current Study

Time in current location EN Diploma 1 1.2

0-2 years 30 35.3 Nursing Degree 2 2.3

3-5 years 29 34 Post Grad Cert 2 2.3

6-10 years 20 23.5 Post Grad Dip 15 17.6

> 10 years 6 7

62

Table 3 Emergency nurse Flagging Behaviour (including Recency and Frequency of Flagging) in relation to Demographics

Have you ever 'flagged'? Recency of flagging Frequency of flagging

Last week or

More than

At least

More than

No Yes more recently

a week ago monthly monthly

n [%] n [%] 2 p n [%] n [%] 2 p n [%] n [%] 2 p

Age

21-40 years

19[22.3] 28[32.9] 0.01 0.92 9 [17.6] 19[37.2] 1.35 0.24 26 [51] 2 [3.9] Fishers 0.49

41-60 years

15[17.6] 23[27] 12 [23.5] 11[21.6] 23 [45] 0 [0]

Gender

Male 4[5.0] 13[15.3] 2.4 0.12 6 [11.8] 7[13.7] 0.01 0.92 9[17.6] 4 [7.8] 0.31 0.58

Female 30[35] 38[44.7] 15 [29.4] 23 [45.1] 21[41.2] 17 [33.3]

Classification

EN 7 [8.2] 13[15.3] 0.27 0.60 2 [3.9] 11[21.6] 0.36 0.55 2[3.9] 11 [21.6] 1.19 0.27

RN 27[31.8] 38[44.7] 11 [21.6] 27 [52.8] 14[27.4] 24 [47.0]

63

Table 4 Emergency Nurse Flagging Behaviour (including recency and frequency of Flagging) in Relation to Experience

Have you ever 'flagged'? Recency of flagging Frequency of flagging

Last week or More than At least More than

No Yes more recently

a week ago

monthly monthly

n[%] n[%] 2 p n [%] no[%] 2 p n [%] n [%] 2 p

Time in Classification

0 -5 years 22[25.9] 33[38.8] 0.00 1.0 19 [37.2] 14[27.4] 0.36 0.54 19[37.2] 14[27.4] 0.97 0.32

6 - > 10 years

12[14.1] 18[21.2] 8 [15.7] 10[19.6] 7 [13.7] 11[21.6]

Time in Emergency Field

0 -5 years 25[29.4] 31[36.5] 1.47 0.22 16 [31.4] 15[29.4] 0.56 0.81 19[37.2] 12[23.5] 0.73 0.39

6 - > 10 years

9[10.6] 20[23.5] 11 [21.6] 9 [17.6] 9 [17.6] 11[21.6]

Time in Current

location

0 -5 years 24[28.2] 35[41.2] 0.04 0.84 18 [35.3] 17[33.3] 0.04 0.83 22[43.1] 13[25.5] 1.39 0.24

> 6 years 10[11.8] 16[18.8] 7 [13.7] 9 [17.6] 6 [11.8] 10[19.6]

64

4.3.1 Emergency Nurse flagging behaviour relating to demographics

Table 3 summarizes the statistical outcomes for nurse „flagging‟ behaviour including

the recency and frequency of „flagging‟ for the demographic categories of age, gender

and nurse classification. Where the expected frequency in one or more cells is less than

five, Fishers exact probability test was used to generate a P value.

(i) Age

Categories of age were aggregated to give greater meaning to data collected from them.

Of the population who indicated „flagging‟, 28 nurses were aged 21-40 years, and 23

were aged 41-60 years. There was no difference in flagging behaviour between the two

age groups (2 = 0.00, P = 0.92). Similarly, there was no difference in recency and

frequency of „flagging‟ between the two age groups, (2 = 1.35, P = 0.24) for recency

and P = 0.49 for frequency from Fishers exact test.

(ii) Gender

Categories of receny and frequency were aggregated in order for greater meaning of

data collected from each category. While 13 males and 38 females indicated „flagging‟,

there was no difference in „flagging‟ behaviour and gender (2 = 2.4 and P = 0.12).

There was also no difference in recency and frequency of „flagging‟ between males and

females, (for recency 2 = 0.01, P = 0.92) and frequency (2 = 0.31, P = 0.58).

(iii) Current classification

While 13 Enrolled Nurses and 38 Registered Nurses indicated „flagging‟, no difference

is reported in „flagging‟ behaviour with 2 = 0.27 and P = 0.60. Similarly, there was no

difference in „flagging‟ behaviour and recency and frequency between classifications

with 2 = 0.36 and P = 0.55 for recency and 2 = 1.19 and P = 0.27 for frequency.

65

Table 4 summarizes the statistical outcomes for nurse „flagging‟ behaviour including

the recency and frequency of „flagging‟ for the categories of time in classification,

emergency field and current location. The majority of nurses indicated 0 – 5 years for

all of these categories.

(iv) Time in classification

There was no difference in time in current classification and „flagging‟ behaviour (2 =

0.0, P = 1.00). Similarly, there was no difference in recency (2 = 3.6, P = 0.54) and

frequency. Similarly, there was no difference in recency (2 = 3.6, P = 0.54) and

frequency (2 = 0.97, P = 0.32) and the two groups.

(v) Time in the emergency field

In addition, no difference existed in time in emergency field and „flagging‟ behaviour

(2 = 1.47, P = 0.22). Also, there was no difference in recency (2 = 0.56, P = 0.81) and

frequency (2 = 0.73 and P = 0.39) and „flagging‟ behaviour between groups.

(vi) Time in current location

Lastly, no difference is reported time in current location and „flagging‟ behaviour (2 =

0.04, P = 0.84). There was also no difference in recency of „flagging‟ (2 = 0.04, P =

0.83) and frequency of „flagging‟ (2 = 1.39, P = 0.24) between the two groups.

(vii) Aboriginal or Torres Strait Islander

From the study data collected no nurse participants were of Aboriginal or Torres Strait

Islander decent therefore no data was tabulated for this category.

66

(viii) Overseas trained

Similarly no meaningful data was tabulated for this category. Only four of the overseas

trained nurses working at the time of the study indicated „flagging‟. Due to the

significant difference in the observations, a Fisher‟s exact probability test was used to

generate a P value of 1.00.

4.3.2 Emergency Nurse flagging behaviour relating to work patterns and

qualifications

Table 5 summarizes the statistical outcomes for nurse „flagging‟ behaviour including

recency and frequency of „flagging‟ for the categories of shifts worked and highest

qualification. Contingency tables were utilized for data reported in two columns and

three rows.

(i) Shifts worked

From the „What shifts do you work?‟ item of the questionnaire, participants were asked

to tick only one box from each of the three categories below:

1. Full-time permanent / Part-time permanent / Casual;

2. All shifts / Day shifts only / Night shifts only;

3. Seven day roster / Monday – Friday / Weekends only.

In Table 2 these categories fell under the subheadings of „Work Status‟, „Shifts

Worked‟ and „Rostering‟. Table 5 summarises this data.

Chi-square value of 0.52 and probability of 0.47 is reported for the groups of shift

status, „full-time permanent‟, „part-time permanent and casual‟. There is no difference

67

between the three groups and „flagging‟ behaviour. Similarly, 2 = 0.32 and P = 0.57 for

„flagging‟ recency and 2 = 0.04 and P = 0.84 for „flagging‟ frequency which implies no

difference between these groups and „flagging‟ behaviour.

For the shifts worked, „all shifts‟, „day shifts only‟ and „night shifts only‟, a difference

between shifts worked and „flagging‟ behaviour does exist. A Fishers exact probability

statistical outcome of P = 0.02 was generated from the data. Nearly all of those nurses

who worked „nights only‟ „flagged‟ while almost none of the nurses who worked „days

only‟ „flagged‟. Almost two thirds of the nurses who worked „all shifts‟ did „flag‟.

However, there is no difference between recency with Fishers P value of 0.24, and

frequency with Fishers P = 0.17.

For the shifts worked, under the heading „rostering‟, Fishers P = 0.03 implying a

difference exists between „flagging‟ behaviour and rostering. No nurses who worked

„Monday to Friday‟ „flagged‟ while all nurses who worked „weekends only‟ „flagged‟.

More than half of the nurses who worked a „seven day‟ roster exhibited „flagging‟

behaviour. For these categories Fishers P values of 0.07 were generated for both

recency and frequency of „flagging‟ behaviour. There was no difference between the

two qualification categories and „flagging‟ behaviour (2 = 0.43 and P = 0.51).

Similarly, there was no difference between „flagging‟ behaviour and the two groups of

qualification with recency (2 = 0.61, P = 0.44) and frequency (2 = 1.00, P = 0.32).

68

Table 5 Flagging Behaviour/Participant Demographics including Shifts Worked and Qualifications

Have you ever 'flagged'? Recency of flagging

Frequency of flagging

Last week or

More than

At least

More t than

No Yes more recently

a week ago

monthly monthly

n [%] n[%] 2 p n[%] n [ %] 2 p n [%] n [%] 2 p

Shifts Worked

Full-time permanent 12[14.1] 22[25.9] 0.52 0.47 23[27.4] 13[15.7] 0.32 0.57 17[19.6] 20[23.5] 0.04 0.84

Part-time permanent 22[25.9] 29[34.1] 25[29.4] 23[27.4] 23[27.4] 25[29.4]

and Casual

All Shifts 26[30.6] 42[49.4] Contingency 30[35.3] 3[3.5] Contingency 28[33.3] 42[49.4] Contingency

Day Shifts Only 6[7.0] 1[1.2] 2cv=12.6 0.0[0] 1[1.2] 2cv=2.67 0[0.] 1[1.2] 2cv=2.02

Night Shifts Only 1[1.2] 8[9.4] =0.1 8[9.8] 5[5.9] =0.1 8[9.8] 5[5.9] =0.1

Seven Day Roster 31[36.5] 48[56.5] Contingency 37[43.5] 43[50.6] Contingency 35[41.2] 45[52.9] Contingency

Monday - Friday Only 3[3.5] 0[0.0] 2cv=6.6 0[0.0] 0[0.0] 2cv=0.18 0[0.0] 0[0.0] 2cv=2.13

Weekends Only 0[0.0] 3[3.5] =0.1 0[0.0] 5[5.9] =0.1 0[0.0] 5[5.9] =0.1

Highest Qualification

Entry Level 20[23.5] 35[41.2] 0.43 0.51 23[27.4] 35[41.2] 0.61 0.44 25[29.4] 33[89.8] 1.0

Specialized 14[16.5] 16[18.8] 15[17.6] 12[14.]1 17[19.6] 10[11.8] 0.32

69

4.4 Section A2 ‘Flagging’

Forty per cent of the sample population indicated not „flagging‟ and half of those nurses did

not „flag‟ because they didn‟t know how to. Table 6 below summarizes the reasons for not

„flagging‟. Most of the reasons given for not „flagging‟ were to do with a lack of

knowledge/awareness regarding the „flagging‟ process.

Table 6 Emergency Nurse Reasons for Not Flagging

If you have NEVER flagged a patient in the ED, why not? Number

of responses

% (n=34)

1. Unaware of flagging process 6 17.6

2. Too busy to flag 1 2.9

3. Don't know how to flag 17 50

4. Uncertain of flagging process 7 20.6

5. Have not experienced an incident serious enough to flag 1 2.9

6. Too many incidents to flag 0 0

7. I am not senior enough to flag 1 2.9

8. The patient is not responsible for actions 0 0

9. Fear of managerial retaliation post flagging 0 0

10. Perpetrator was provoked by staff 1 2.9

11. Too distressed to flag post incident 0 0

12. Patient is aiming aggression at the hospital, not me 0 0

13. The patient has been flagged previously 0 0

14. The patient's presentation is legitimate 0 0

Total 34 100

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4.5 Section B: Patient-related Factors

Table 7 below summarizes the five patient behaviours that were most commonly EVER,

ALWAYS and NEVER „flagged‟. „Threat to harm‟ and „Aggressive statements‟ were most

„flagged‟ by nurses. Very close to no nurses would never „flag‟ these patient behaviours.

Patient behaviours like „Walking back and forth to the nurses‟ station‟, and „Walking around

confined areas‟ were more tolerated and hardly „flagged‟ at all.

Table 7 Patient-related Factors Ever, Always and Never Flagged

Patient Behaviour EVER Flagged

ALWAYS Flag

NEVER Flag

n= 51 (%)

n= 85 (%)

n =85 (%)

Threat to harm 95.3 87.0 1.0

Aggressive statements

100.0 86.0 1.0

Intimidation 82.4 80.0 6.0

Yelling 84.3 63.5 9.0

Belligerence 51.0 52.0 19.0

The following graph in Figure 1 below demonstrates the frequency of patient behaviours

ever, always, never and most likely „flagged‟ by emergency nurses. All 17 patient

behaviours were ever „flagged‟ even if only by at least a couple of participants. Half of the

nurses who ever „flagged‟ indicated „flagging‟ the two patient behaviours „threat to harm‟

and „aggressive statements/threats‟. Other behaviours unlikely to be tolerated by nurses, and

71

therefore „flagged‟, although to a lesser extent, were „intimidation‟ and „yelling‟. Patient

behaviours never „flagged‟ the most were „walking back and forth to the nurses‟ station‟

(56%), „irritability‟ (53%), „walking around confined areas‟ (52%) and „increase in volume

(speech)‟ (50%). From the graph it is obvious that a difference exists between patient

behaviours which are tolerated and not tolerated amongst nurses. It is also evident that a

relationship exists between the patient behaviours „threat to harm‟ and „aggressive

statements/threats‟ amongst the categories „always flag‟ and „most likely to flag‟ indicating

that given those nurses who don‟t „flag‟, (mostly due to a lack of knowledge of the „flagging‟

process), they would certainly be most likely to „flag‟ the same behaviours as those that do

„flag‟. The patient behaviours that were never „flagged‟ are various ranging widely between

all 17 behaviours. This is indicative of acceptance of these behaviours to varying degrees

amongst emergency nurses and that these behaviours are experienced regularly in the

workplace.

In addition to the patient behaviours listed in the questionnaire and represented in the graph

in Figure 1, participants elaborated on patient behaviours most likely to be „flagged‟ in the

free text item of the questionnaire. Major patient behaviours are, „actual physical assault‟,

„carrying of weapons‟, „code blacks‟ and „Police/Star Force involvement‟. These behaviours

were not listed in the questionnaire tool. These behaviours are also more extreme than those

behaviours in the questionnaire based on the cues from the studies done by Luck et al 2007

and Wilkes et al 2010. This may indicate that nurses are exposed to other more acute

experiences of violence. (Examples of participant responses can be found in Appendix 14:

Participant Free Text Responses to Item B1.2). All nurses across all focus groups expressed

with concern some degree of experience of or exposure to physical violence while at work.

72

Figure 1: Emergency Nurse Flagging Behaviour and Patient Related Behaviours

73

4.6 Section C: Nurse Attitudes, Practice and Knowledge of ‘Flagging’ in the ED

In section C of the questionnaire participants were invited to place their responses in

order of preference on a Likert-Scale numbering 1 to 5 where 1 is assigned to strongly

disagree and 5 to strongly agree. Items C1.1 to C1.5 pertained to nurse attitudes towards

„flagging‟. Table 8 summarizes this data. The majority of nurses (70.6%) strongly

agreed to „flagging‟ patients who direct violence at them personally while half as many

strongly agreed to „flagging‟ patients who direct violence at the hospital system.

Similarly, roughly half the nurses also indicated strongly agreeing to „flagging‟ patients

who may not be responsible for their violent behaviour due to illness. From the focus

group interviews this was further elaborated upon with some nurses stating that “the

patient may have a urinary tract infection and therefore be confused” or the patient may

be “post-ictal” and therefore not warranting a „flag‟. However, violent presentations

involving self-induced symptoms such as “intoxication”, “substance abuse” and

“detainment in the community” were more likely to be „flagged‟.

74

Table 8 Emergency Nurse Attitudes to Flagging

Nurse attitudes towards flagging strongly disagree

disagree neither agree strongly

agree

n (%) n (%) n (%) n (%) n (%)

C1.1 Patients who direct violence 0 0 4 21 60

at me should always be flagged. (0%) (0%) (4.7%) (24.7%) (70.6%)

C1.2 Patients who direct violence at the 2 3 9 34 37

hospital system should always be flagged. (2.3%) (3.5%) (10.6%) (40.0%) (43.5%)

C1.3 Violent patients who may not be 3 4 17 28 33

responsible for their behaviour due to (3.5%) (4.7%) (20.0%) (33.0%) (38.8%)

illness should always be flagged.

C1.4 Violent patients whose illness 1 3 9 38 32

affects their self-control should always (1.2%) (3.5%) (10.6%) (44.7%) (37.6%)

be flagged.

C1.5 I am more likely to flag a patient if I view their presentation as unwarranted

15 11 32 18 9

or inappropriate. (17.6%) (12.9%) (37.6%) (12.2%) (10.6%)

Items C1.6 to C1.10 pertained to nurse practices of „flagging‟. These practices are

summarized in Table 9. Of the population (n=85) the majority of nurses strongly

indicated „flagging‟ to protect their colleagues and equip nurses against violence.

However, hardly any consensus existed amongst nurses as to whether they feel safer in

the ED because of „flagging‟

75

Table 9 Emergency Nurse Practices of Flagging

Nurse practices of flagging strongly disagree

disagree neither agree strongly

agree

n (%) n (%) n (%) n (%) n (%)

C1.6 I flag to help reduce the trajectory of 3 3 27 17 35

violence in the ED. (3.5%) (3.5%) (31.7%) (20.0%) (41.2%)

C1.7 I flag to help protect my work 0 0 25 14 46

colleagues. (0%) (0%) (29.4%) (16.4%) (54.0%)

C1.8 I flag to equip ED nurses against 0 0 27 16 42

violent patients. (0%) (0%) (31.7%) (18.8%) (49.4%)

C1.9 Flagging makes me feel safer in 9 12 22 22 20

the ED. (10.5%) (14.0%) (25.8%) (25.8%) (23.5%)

C1.10 I always observe violence alerts on 3 5 13 31 32

flagged patients before approaching them. (3.5%) (5.8%) (15.3%) (37.5%) (37.6%)

Table 10 summarizes nurse knowledge of „flagging‟ behaviour collected from items

C1.11 to C1.14. Of the population (n=85) nearly all nurses were unaware of a hospital

policy for „flagging‟. In spite of this vast unawareness, greater than 90% indicated their

reliance on the „flagging‟ system by indicating that they would never remove a „flag‟

from a patient.

76

Table 10 Emergency Nurse Knowledge of Flagging

Nurse knowledge of flagging yes no don't know

n (%) n (%) n (%)

C1.11 Is there a hospital policy 4 8 72

for flagging? (4.7%) (9.4%) (84.7%)

C1.12 Is there a process for 8 7 68

removing a flag from a patient? (9.4%) (8.2%) (80.0%)

C1.13 Have you ever removed 3 77 4

a flag from a patient? (3.5%) (90.5%) (4.7%)

C1.14 Would ever remove a 6 64 14

flag from a patient? (7.0%) (75.0%) (16.4%)

4.7 Section D Nurse Perception of Flagging in the ED

Items D1.1 to D1.6 pertained to nurse perception of „flagging‟ from the population

(n=85) of emergency nurses. Table 11 summarizes this data. Two items (D1.3 and

D1.5) encompassed a „no difference‟ option, whereas other items were „yes/no/don‟t

know‟ responses. Item D1.1 indicated that almost three quarters of nurses agreed that

„flagging‟ was a part of the nursing duty of care. However, only a third indicated using

the IF18 Violence incident report form following a violent incident. A total of 10 nurses

commented on why they didn‟t use this form in the free text section. Seven of these

respondents reported that they were unaware of this form; two nurses stated that they

were too distressed to use it and one nurse implied that there was no benefit to using the

form. Item D1.5 revealed that almost all nurses (91.8%) perceived that information on

Mental Health patients should be linked to EDIS. Item D1.6 was an open ended

question. In response to this item, seven nurses indicated that previously placed „flags‟

77

on patients made no difference to nursing care interventions although they admitted to

becoming hyper-vigilant around the „flagged‟ patient for fear of harm. This was

evidenced as a protective measure against nurse „burnout‟ in the focus group interviews.

The majority of participants commented on becoming more cautious around previously

„flagged‟ patients and expressed becoming “suspicious of the intent of these patients.”

Some nurses admitted to “asking another nurse to accompany” them on first approach

or “arranging for security to be close by.” Several respondents interpreted previously

placed „flags‟ on patients as triggers for interacting less with these patients and

expressed being “fearful of getting hurt by them” and “withdrawing due to increased

fear.” This was further elaborated on in the focus group interviews which revealed that

workplace violence had become a substantial source of increased stress levels and that

nurses had to deal with this in some manner. Descriptions of attempts to avoid such

incidents are reported under the sub-categories of major themes „emotional trauma‟,

„increased stress levels‟ and „self-protection‟.

A general consensus was evident among all participants that the practice of observing

previously placed „flags‟ was a definite means of risk management. Without violence

alerts violent patients were said to have “an advantage over us.” „Flags‟ are used by the

majority of nurses every day to “get a good idea of the background” of the patient as it

“makes me more cautious.”

78

Table 11 Emergency Nurse Perception of Flagging

Nurse perception of flagging in the ED yes no

no difference

don't know

n (%) n (%) n (%) n (%)

D1.1 Is flagging a part of the nursing 56 5 N/A 24

duty of care? (65.9%) (5.9%) N/A (28.2%)

D1.2 Do you agree that violence flags 2 59 N/A 24

already placed on patients should ever (2.3%) (69.4%) N/A (28.2%)

be removed?

D1.3 Does experience gained with 5 4 42 34

exposure to violence cause you to flag (5.9%) (4.7%) (49.4%) (40.0%)

less or more?

D1.4 Have you ever used an aggression 33 50 N/A N/A

violence report form IF18 to report a (38.8%) (58.9%) N/A N/A

violent incident in which you have been

involved?

D1.5 Do you feel that patient information 78 0 1 6

regarding violent history known by the ED (91.8%) (0.0%) (1.2%) (7.0%)

Mental Health team should be linked to the

EDIS, (flagging) system?

However, all nurses agreed that „flagging‟ was “not the answer to the problem of

violence.” and agreed that “We shouldn't have to be exposed to it or threatened.”

„Flagging‟ was useful in making nurses “aware of potential for danger” but, “it doesn't

prevent its existence in ED.” „Zero tolerance to violence‟ in ED was thought of as an

anomaly and a profound source of frustration leaving nurses feeling “sceptical about

efforts made to protect nurses.” This was clearly expressed by one nurse who wrote,

“Zero tolerance doesn't equal the daily experience of violence.” Further expression of

this issue later developed into the major theme “Risk management of violence‟ in the

thematic analysis.

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4.8 Analysis of Focus Group Interviews

Thematic analysis

During the focus group interviews there were five open-ended questions posed to each

participant. These questions sought information about why nurses „flag‟ violent patients

in the ED. All of the participants appeared relaxed at the start of the interviews and were

enthusiastic to answer all of the questions. Some of the responses led to in-depth

emotionally charged discussions between participants. All discussions were tabulated

verbatim in Appendix 15. Thematic analysis enabled reporting of participant

experiences offered during the interviews. After reading the transcripts many times over

and becoming familiar with the contents, themes and patterns were identified which

yielded comprehensive awareness of the collective experience of interviewees. Emerged

themes gave deeper insight to the questionnaire items. The following discussion

provides a thematic description of the data collected which related to why nurses „flag‟

violent patients. A total of 158 statements/phrases were digitally recorded during the

interviews in which the following five questions were asked:

1. How effective do you think security is in the emergency department against

violent patients?

2. Do you feel that toleration to violence is an expected part of your job?

3. Are you equipped to deal with violence at work?

4. Does experience of and exposure to workplace violence impact on you

personally?

5. Are you supported by management in relation to workplace violence?

80

All statements were scribed, examined and grouped together forming nine sub-

categories. These sub-categories were compiled into three major themes which revolved

around emergency nurse experience of workplace violence. These identified areas

assisted with the discussion in chapter five. (See Figure 2 below: Flow Chart of Major

Themes Stemming from Experience of Workplace Violence). The nine sub-categories

and associated significant statements/phrases are described below.

4.8.1 Major Theme: Impact of Violence

This theme is composed of the following five categories:

(i) Physical Harm

According to the SA Health Prevention and Management of Workplace Violence and

Aggression Guidelines (2009), the definition for physical violence is: „The use of

physical force against another person or group that results in physical harm‟. Experience

of physical violence was not an uncommon occurrence in the ED for interviewees

across all groups. Physical violence was either personal or witnessed. Some nurses

relayed memories of colleagues who suffered inability to work in the ED as a result of

these incidents. Nurse [a] from Group 1 stated: “Nurses are the first point of contact and

get hit the most.” and nurse [c] from Group 3 stated, “Nurses are caring people and

therefore soft targets.” Nurse [d] from Group 1 conveyed the following statement; “I

got bitten once while defending myself from a patient with a knife.” Physical violence

was described as inescapable. Nurse [e] from Group 2 raised the question: “SAAS

[South Australian Ambulance Service] doesn‟t even get out of the ambulance if they are

called to a violent situation. Why do nurses have to put themselves in harm‟s way?”

81

(ii) Emotional Trauma

All nurses agreed that workplace violence was becoming a routine occurrence and that

because of this many suffered affects such as sleep deprivation, increased stress levels,

and long/far ranging effects on their personal, family and social lives. Nurse [f] from

Group 2 stated: “Violence makes a massive impact on stress levels. Some nurses have

serious ongoing problems because of it. There‟s no doubt that it affects all our staff.”

Examples of this are given by nurse [k] from Group 3 who stated: “I am still affected by

a siege which took place eighteen months ago.” and nurse [f] from Group 2 who said: “I

had a sawn off shotgun pulled at me at triage. That affected my career and me.” Group 3

nurses [i] and [k] added: “It affects you in the end and it keeps affecting you and it

keeps affecting everyone around you. It just doesn‟t affect you here, it affects home as

well. You want it to stop.” and “You can‟t get it out of your mind. You internalize it and

deal with it anyway you can.” The effects of work-related stress, originating from

violence, were conveyed by nurse [g] from Group 2 who stated with remorse: “I know a

nurse who used to work here and she used to be a clever, clever girl. But now she is a

mental health patient. It‟s a real shame.”

(iii) Low moral

All nurses found difficulty in sustaining a good work ethic whilst confronted by violent

patients and stated that they suffered various levels of depression and hopelessness post

incidents involving physical and verbal violence. Some stated that these episodes threw

them “off balance” and induced low levels of self-confidence and confusion while

performing nursing duties. For example, nurse [h] from Group 2 stated: “You try to do

the best you can to assist people because you‟re a nurse, but then you get treated worse

than a dog in return and wonder why you bother.” Nurse [c] from Group 1 asked: “How

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Major Theme:

Self-

protection

from Violence

Major Theme:

Risk

Management

of Violence

Major Theme:

Impact of

Violence

Workplace

Violence

are you supposed to feel when you‟re being told that someone is going to kill you and

they‟ve got a loaded gun? He knew my name, he knew where I worked and he had a

loaded gun. I didn‟t exactly feel confident after that.”

Figure 2 Flow Chart of Major Themes stemming from the experience of Workplace Violence

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(iv) Increased Stress Levels

All participants expressed that workplace violence simply intensified existing stress

levels existing from daily departmental overcrowding and under-resourcing. This was

evidenced by such statements as: “Violence increases stress levels – end of story.” by

nurse [g] from Group 2 and “I‟m getting really sick of violence.” (nurse [h] Group2)

and “I used to be normal” nurse [c] Group 1.

This was best described by the interviewee [f] in Group 2:

I think our society is a lot more egocentric and nurses have lost

respect. More aggression and violence is used as a tool to get

what you want on a daily basis. Our resources are further and

further stretched too and we‟re less and less able to meet

people‟s needs. As we get busier and busier, we are more likely

to experience escalating behaviour which means we are

constantly under stress. This sort of environment is not

sustainable.

(v) Burnout

Interviewees across all groups unanimously conceded to feeling “weary” regarding

contending with violent patients and likened the work environment to a “war zone”.

Nurse [g] from Group 2 stated: “Funnily enough, I didn‟t think I would be working in a

combat zone.” Concern was expressed by nurse [d] in Group 1 who described nursing in

the ED by stating:

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Nursing is changing. You go to a course to learn how to give

medications. You don‟t think you go to a course to learn how to

defend yourself. Part of the nursing uniform should be a stun gun

or Taser. Before I came into nursing I didn‟t think I would need

to source solutions for protection and survival from violence. I

guess it was naïve of me and I realize that I need to develop

coping mechanisms but most days I am stretched to the limit and

go home absolutely frazzled.

4.8.2 Major Theme: Risk Management of Violence

This theme is composed of the following three categories:

(i) Violence Unaddressed

All groups held an unprecedented belief that violence in the ED was ignored by

management and felt insulted and unsupported by unevaluated efforts made to address it

despite its escalation. All nurses agreed that they felt they should “shut up and put up”

with violent patients and take personal responsibility for safety. Nurse [f] in Group 2

stated:

The only choice that the emergency nurse has, real choice, is to

either stay or go. That‟s the only effective way of stopping the

violence. The only way to make it really happen is to leave.

Under the OH&S Act, we are expected to make sure we don‟t put

ourselves in danger and, unfortunately, emergency culture is

such that we do.

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The true extent of violence was believed to be “unmonitored” by management and not

enough was being done even though staff “have a right to a safe work place” and

“management have a duty of care to provide it”. The issue of the reality of feeling

“forced to accept violence” contradicting the written policy “zero tolerance to violence”

was continuously expressed across all groups. All nurses agreed to an expectation to

accept “bad behaviour”. Nurse [g] in Group 2 stated: “I am made to feel incompetent of

carrying out my duties if I don‟t accept violence.” This was well described by one nurse

[d] in Group 1:

Why do we have the „no tolerance to violence‟ signs? We should

have the right to call Police and have a patient removed without

discussing the situation. As far as I‟m concerned, if you feel you

are threatened enough that you need to call the Police, you

shouldn‟t have to go through the Flow Coordinator or the Duty

Nurse Coordinator or security. You should be able to make the

decision and be supported. If every time it happened, the Police

were called, and it wasn‟t tolerated, it would show that we don‟t

tolerate it. Instead we promote this behaviour.

(ii) Security

All interviewees expressed various levels of dissatisfaction of measures such as security

guards and previously implemented duress pendants to address violence. Nurse [j] from

Group 3 stated: “Security guards don‟t change anything because people don‟t respect

them because they have no power and if we had a Police Officer sitting in the ED,

maybe people might think twice.” Concerns were unanimously raised about the length

of time taken for security to arrive when required. Nurse [c] in Group 1, describing a

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violent incident, stated that: “After the four calls a response was initiated, but it took a

good five minutes and by then everyone could have been dead.” All agreed to a need for

“security guards based in the ED because this is where the escalations of violence

always happen.” Duress pendants were described as “useless” in the prevention of

violence and looked upon as “…a button to say I‟m in trouble, while actually accepting

the fact that we‟re going to be in trouble.” Nurse [j] from Group 3 reported that “It‟s an

acceptance of the fact that the problem is escalating.”

(iii) Lack of Support

Lack of education/training, debriefing sessions, feedback from incident reports, and

“belittling” during incidents by managerial members served to “compound” feelings of

“vulnerability” amongst all participants. A concern of “having nowhere to turn” was

evident amongst the majority of participants. Nurse [d] from Group1 expressed this by

describing the following incident:

One patient snapped at 06:58 hours and the situation got out of

control and he barricaded himself in the cubicle. He threw

everything he could at us. He threatened us with hands full of

syringes and said, „The next one that comes through the door is

going get stabbed‟. The Duty Nurse Coordinator goes, We‟ve got

to see that he‟s ok. Let‟s open the door. I said, Are you for real?

While he‟s screaming and punching holes in the walls he‟s fine.

You‟re going to put us at risk to open the door to see he‟s alright.

We ended up getting Star force in. Nobody was debriefed on that

shift.

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Other participants made statements such as: “When you get hurt, there‟s no back-up, no

support.” and “There‟s no follow-up to how we‟re feeling emotionally.” Besides

„flagging‟, a small number of nurses indicated submitted IF18 – Aggression and

Violence Incident Report Forms after experiencing extreme violence despite feeling

“sceptical” about the benefit of this. Nurse [f] from Group 2 described an experience of

submitting these forms by stating:

I know of one person who was called into the office and all their

IF18 forms had been collected and they were made to justify

their reports of violence. After that I haven‟t put one in because

you think, Is this meant to be information that they collect to see

how at risk we are or is this evidence against me?

In addition to this nurse [h] from the same group stated:

You see your colleagues who have experienced a violent episode

and have gone up to stick up for themselves and you see the

repercussions and how weren‟t supported and it makes you

think…Well, why should I stick up for myself if it‟s going to make

it worse for me and nothing‟s going to change? Then you think,

well if you‟re asking management for support and it turns

around and becomes YOU should have done this or YOU should

have done that then what‟s the point? We shouldn‟t have been in

a violent situation in the first place and it shouldn‟t have to turn

around to be our problem or fault. It‟s not our fault.

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Feelings of “betrayal” from management “mind-boggled” participants and “infuriated”

others as nurses believed that “You shouldn‟t have to feel that our registrations will be

taken away if we can‟t develop resilience to violence. We shouldn‟t have to feel like our

safety and health is not being looked after.” (Nurse [a] Group 1). On closer

examination, the issue of violence was found to always be unaddressed – even from the

day of job interview. One participant recalled: “I think everyone has some

understanding that ED can be a scary place but no one at any stage during interview sits

down and asks you if you are aware that violence incidents in the ED that may require

intervention due to extreme duress occur. You‟re just not told that.” (Nurse [f] Group

2). Apart from this, all participants conceded that they felt “unequipped‟, “unprepared”,

“untrained” to “act in violent situations” at work. Without “unity”, “protocol” or

“support”, it was difficult to formulate a notion of “rights” for the nurse. In fact all

participants felt that they had “no rights”. Nurse [j] from Group 3 stated: “I think that

there are people higher up [management] who think that the rights of the patient are

more important than the rights of the nurse”.

4.8.3 Major Theme: Self-Protection from Violence

This theme is composed of the following two categories:

(i) Violence: a part of the job

All interviewees across all groups agreed to violence being “a part of the job”, even

though it “shouldn‟t be accepted”. Most participants were resigned to accepting that it

was only “a matter of time” before violence would “take its toll” and at that stage their

emergency nursing career would cease. Nurse [d] from Group 1 stated:

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Every day that we‟re here is a bonus day because the minute

something happens to me which jeopardizes my safety or mental

stability, the job goes. I am not committed to emergency nursing

to the point where I will jeopardise myself or anyone else just to

help these people who treat you like crap.

(ii) Self-defence

All participants indicated that to stay in the field of emergency nursing, measures of

self-protection were necessary since “It‟s not a good feeling that management is not

going to be behind you in those situations and that you have to protect yourself and your

colleagues.” (Nurse [e] Group 2). Nurses felt they were forced to be “self-resourceful”

and “increase resilience” and “coping mechanisms” to remain in the emergency field.

Nurse [l] from Group 3 stated: “You go into a protective state because you know that

it‟s not going to change. You take measures to protect yourself.” In order to do this,

some participants eluded to “backing off” from nursing care. Nurse [c] from Group 1

commented: “We are justified in exhibiting marginalized care to patients exhibiting

violent behaviour. What else are you going to do? We‟re human.” Additionally, nurse

[b] in Group 1 stated: “I will say to a Doctor, I will not be treating this patient. I am not

going to be smacked in the face, or pushed or shoved anymore.” Levels of exasperation

rose as participants raised the issue of “being brought to justice” if they were to

“physically assault an individual in public” while at work “a violent patient gets off

Scott-free after assaulting a nurse”. This was best described by nurse [c] in Group 1

who stated: “There is no safety. There is no Police Officer standing at the door saying

you are under arrest. There is no consequence for violent actions against us.”

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4.9 Conclusion

Both qualitative and quantitative data collection techniques contributed to the data

reviewed in this chapter. The various data sources were analysed separately.

Demographic data from the study questionnaire revealed that the participants were

incomparable in age, gender, career experience and „flagging‟ behaviour. However, a

statistical significance was reported between „flagging‟ behaviour and „shifts worked‟

with nurses who work „day shifts only‟ and „Monday to Friday‟ „flagging‟ significantly

less. Most nurses that didn‟t „flag‟ didn‟t have an awareness of the „flagging‟ process

and the majority of all nurses did not have an awareness of a hospital policy for

„flagging‟. However, „flagging‟ was reported to be a main source of mediation for

danger between nurses and violent patients and relied on heavily for this. „Flagging‟

was perceived as a fundamental duty of care by most nurses for protection from harm.

All of the qualitative data threw light on the phenomenon of why nurses „flag‟

emergency patients. Not only was violence portrayed as an issue experienced by all

nurses in this study, but types of violence were described as becoming more extreme. In

light of this, emergency nurses were left to fend for themselves and did so by averting

violent patients who they identified and „flagged‟. However, past history of violence of

those patients perceived as having the most potential for violence, (Mental Health

patients), was not relayed to nurses who have most interaction with them. Nurses

reported no departmental establishment for the relaying of this vital information. All

emergency nurses reported suffering ongoing various degrees of violence-related stress

effects and a consensus of vulnerability was exposed. Despite heavy reliance on

„flagging‟, „flagging‟ made little difference to nurses feeling safe at work. This

vulnerability was compounded by evidence of expressed scepticism due to an attitude of

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non-awareness of the extent of workplace violence by management. Most nurses

believed that law enforcement would assist with prevention of harm from violence

thereby giving relief.

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CHAPTER 5: DISCUSSION

“This fellow came into triage swearing and carrying on because he had missed his

depot injection by a week and made it our problem. I told him that he needed to go to

Northern ACIS to get it sorted. He bashed on the glass triage window and carried on.

He was told that he needed to calm down or we wouldn‟t help him. We tried to get

information out of him regarding his issue. This guy just cracked it and pushed his fist

three or four times at the glass as hard as he could and was told, Sorry, you can leave.

We‟re not accepting that behaviour at all. A code black was called because he had

kicked in both of the sliding doors and broke the glass on one of them. The Duty Nurse

Coordinator spoke to us before she went out to the code black and asked us what had

happened. In the end she convinced him that he could come back in and be treated. We

got made to look like dickheads. We were trying to reinforce the zero tolerance sign in

view but she reinforced his bad behaviour instead. She basically made us look like

idiots.” (Nurse [b] Group 1 of the focus group interviews).

5.1 Restatement of the Problem

Although it is well documented that nurses are at risk of violence in the ED, little data is

being generated about how to improve this situation (Di Martino 2003; International

Council of Nurses 2002; McPhaul & Lipscomb 2004). Violence is now widely

considered as part of the emergency nursing job (Deans 2003; Ferns 2005a; Munro

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2002). Consequently, emergency nurses are at high risk for assault and are regular

targets for attack. Although the workplace should be free of violent threats and acts, the

majority of nurses do not feel safe at work and are becoming increasingly concerned by

the perceived lack of managerial support and proactive input for addressing this acute

problem (Holmes 2006; Keely 2002; ICN 2009). The bulk of emergency nurses believe

their concerns are being ignored by administrators and implemented policies are

unrelated to their experienced reality (Ferns & Chojnacka 2005; Greco et al 2006;

Strockowski 2010). In fact, it is now recognised that in addition to this lack of support,

nurses are punished for retaliating against acts of violence or accused of instigating

them (Gacki-Smith et al 2009; ICN 2009). Although management is bound by legal and

ethical responsibilities to reduce staff hazards - (ANF Policy 2008) - it appears that this

is replaced by an administrative culture that refuses to acknowledge the true extent of

existing risks (Gacki-Smith et al 2009). Nurses feel that they are left to their own

devices for protection in order to survive and have therefore developed a culture of their

own comprising peripheral care and/or marginalization of violent patients (Aleandri &

Sansoni 2006; Chapman & Styles 2006; Di Martino 2003; Merfield 2003). Since the

researcher was concerned for the health care response to violent patients, and outcomes

for injuries sustained during acts of interpersonal violence for this population, as well as

the influence nurse exposure to acts of violence may have on nurses and their nursing

care delivery, two issues were of main interest to this study: factors affecting nurse

reporting of workplace violence in ED, and their perspectives of the impact of

workplace violence on nursing performance. Therefore the statement for the research

question became; „Factors exist which influence emergency nurses to electronically

chart violence alerts on emergency patients‟. The following research question was

formulated; „Why do nurses electronically chart violence alerts on, (or „flag‟),

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emergency patients?‟ Additionally, a better understanding of nurse‟s knowledge,

attitudes and practices of „flagging‟ patients was addressed in this research.

5.2 Summary Description of Procedures

Since triggers for „flagging‟ were under scrutiny, variables such as nurse-related factors

and patient-related factors for „flagging‟, frequency and recency of „flagging‟, and nurse

attitude, practice, knowledge and perception of „flagging‟ were chosen as constructs for

the proposed survey. The literature review identified two findings of similar tools used

in studies on predictive cues for, and nurse assessment of potential patient-related

violence (Luck, Jackson & Usher 2007 & Wilkes et al 2010). The study tool was

developed from these two tools, piloted, evaluated and modified over a period of four

months.

Following revision of the original application both the University of Adelaide and

CNAHS Ethics Committees approved the study and survey in June 2011.

A mixed methods approach for this research was decided upon. Both quantitative and

qualitative data were collected from a self-reported, structured questionnaire and semi-

structured focus group interviews. Non-parametric statistics (Chi-square, contingency

tables) and thematic analysis of the focus group data were used.

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5.3 Major Findings and Their Significance to Clinical Practice

As the first study of this hospital‟s emergency department‟s „flagging‟ process and why

emergency nurses „flag‟ emergency patients, this study provides significant

contributions to our understanding of emergency department violence. The study

showed that emergency department workplace violence is a highly prevalent issue

among nurses in this study. These findings stress the seriousness of this issue.

Of the 85 nurses who took part in the survey, 51 indicated „flagging‟ and 34 indicated

never „flagging‟. Most of the 34 who never „flagged‟, did not know how to or were

either uncertain or unaware of the „flagging‟ process. Additionally, Section C of the

questionnaire identified that 72 of the 85 nurses were unaware of a hospital policy for

„flagging‟.

Although the researcher conducted an investigation of hospital policy for the

management and regulation of workplace violence prior to the development of the

questionnaire, no formal policy could be found for the specific process of „flagging‟

violent patients. Both the hospital intranet site and questioning of technical, security,

educational and administrative staff did not produce specific means for retrieval of this

information. Despite the availability of the „flagging‟ process, its implementation was

not formally imparted or its use encouraged. Of those nurses who did indicate „flagging‟

most admitted to “picking it up on the job” from fellow colleagues rather than being

“formally educated prior to commencing employment in the ED”. This usually occurred

after witnessing the implementation of the „flagging‟ process prompted by a violent

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incident taking place. Nurses who lacked knowledge of the „flagging‟ process may have

been placed at a reduced opportunity for self-protection from harm as they did not

recognise what the „flag‟ indicated. This reduced rate of „flagging‟ may not only have

enhanced danger, but reflected a false reality of the true context of the issue of ED

violence. This finding is supported by studies concerning barriers to nurse reporting and

measurement of violence in the ED (Ferns 2005a; Erickson & Williams-Evans 2000;

Gerberich et al 2004)

In addition to this no specific formal criteria could be obtained for the identifiable cues

nurses associated with „flagging‟ violent patients. This implied that the decision to

„flag‟ or not to „flag‟ was subjective on behalf of the nurse. This finding reflects

research which identifies the elusiveness of the nature of violence and the consequential

varied definitions and interpretations that constitute unreliability of reporting rates of

ED violence (Ferns 2005a; Luck, Jackson & Usher 2007; McPhaul & Lipscomb 2004).

The greatest „flaggers‟ were nurses who worked weekends only at 3/3, followed by

nurses who worked night shifts only at 7/8. This is most likely due to incidents of

violence occurring most often at night and on weekends when presentations involving

intoxication, substance abuse and interpersonal violence were increased. Administrative

staff, who don‟t work during these periods never or hardly ever „flagged‟.

Interestingly enough, all 17 patient behaviours/cues resulting from the study by Wilkes

et al (2010) were „flagged‟. The behaviours „threat to harm‟ and „aggressive

statements/threats‟ vastly out ranked all others and were also the most likely to be

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„flagged‟. From the graph in Figure 1 it is also obvious that approximately half of the 17

patient-behaviours were well considered by participants to be tolerated as “low level

violence” and overlooked because of their day-to-day occurrence. Nurses admitted to

these behaviours being “inescapable” and therefore “part of the job”, or “normal”

despite policy which rejects tolerance to violence. This acceptance of violence in ED is

supportive of literature concerning toleration of violence in the ED by nurses and

relative to perceived risk of harm (Di Martino 2003, Gacki-Smith et al 2009).

No relationship existed between nurse demographics and „flagging‟ behaviour, because

all nurses that „flag‟, (regardless of their demographics), who work on the floor, feel the

need to use the „flagging‟ system as a means of protection from harm. The vast majority

of nurses strongly agreed to „flagging‟ patients who directed violence at them

personally. Even those who didn‟t „flag‟ indicated that they would most-likely „flag‟

these patient factors.

The findings from this study concerning violence in the ED are consistent with the

research literature involving nurses in other International emergency departments. The

qualitative findings from the focus group interviews further support the research

literature in that participants indicated three major issues concerning workplace

violence. These are discussed below.

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(i) Impact of violence

Findings from literature reveal that ED nurses are the first point of contact with the

surrounding community occupants in times of need (Fernandez et al 1999; Mayhew &

Chappell 2003). These needs are acute, chronic, various, complex, multiple and

continuous. These nurses attempt to meet these needs with limited resources and as a

result, levels of irritation and frustration among patients are permanent varying only in

degrees (Crilly et al 2004; Fernandez et al 1999; May & Grubbs 2002). These findings

support the outcomes of this study in that violence against nurses in the emergency

department was not uncommon and that levels of violence erupted into anger during

which nurses became “soft targets for violent attack”. This was indicated in the focus

group interviews.

Literature indicates that emergency nurses are prone, through media portrayal, to

believe that the use of violence is an acceptable means of communicating and fulfilling

needs (Ferns & Chojnacka 2005). Many patients who present are victims and

perpetrators of violence within the cycle of violence and express violence as a normal

means of communication (Corum 2006; Day et al 2004; Indemaur 1999). In addition,

many patients are intoxicated, drug-affected, psychotic, suicidal and/or homicidal.

These conditions are prevalent in society and met by nurses with dismay at the doors of

emergency departments (Keely 2002; Kowalenko et al 2005). Findings from this study

reflect this literature as all participants across all focus groups expressed belief that

workplace violence was routine in the ED and involved violence induced by

“intoxication”, “substance abuse” and/or “Mental Health”. Ongoing experience of this

routine violence expressed by the participants was stated to be responsible for their

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“sleep deprivation”, “increased stress levels” and “far ranging negative effects on the

personal, family and social lives”. Participants found difficulty with “unwinding” after

violent episodes at work. Some nurses reported taking “stress leave”, “seeking

counselling” and mentioned colleagues who had resigned as a result of experiencing

extreme and/or chronic workplace violence. All participants stated that they suffered

reduced “self-confidence”, “morale” and “work ethic” due to exposure to and

experience of routine violence. In addition, interviewees expressed bearing with degrees

of “vulnerability”, “depression”, “hopelessness”, “anxiety” and “burnout”. The majority

of participants in this study strongly agreed to a heavy reliance on „flagging‟ which was

perceived to reduce the trajectory of violence, protect their work colleagues and equip

themselves against violent patients.

(ii) Administrative and managerial responsibility

This study found that emergency nurses perceived that issues of workplace violence

were unaddressed by nursing management. They expressed bewilderment and concern

over extreme incidents, which were reported using the IF18 form, but not appearing to

be “followed up”, “evaluated” or “responded to”. Some nurses mentioned that they felt

“punished” or “belittled” for reporting violence and had to “justify their reports”. Most

nurses perceived reporting to be of “no benefit”. Participants believed that

“interrogation” from management about reports compounded their frustration and levels

of stress. They also reported feeling pressured when their individual levels of

“resilience”, “responsibility”, “resourcefulness”, “competence” and “coping

mechanisms” came “under scrutiny”. Participants were made to feel undervalued when

other staff supported and promoted bad behaviour exhibited by patients, (vindicating the

rights of the patient). These findings, as well as expectations of other staff to justify

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claims of violence and getting hurt, are distinct barriers to reporting violence. This is

supported by a recent study by Gacki-Smith et al (2009) entitled „Violence against

nurses working in United States Emergency Departments‟. Despite established policy

guidelines for safety against violence in the ED, nurses believed that they were expected

to accept violence as “part of the job”. Participants accepted what they called „low level

violence‟ which amounted to name calling, slandering, glaring and staring, belligerence

and refusal of care. Some nurses accepted slapping, lunging and spitting within this

category of violence too. However, the expectation to accept levels of violence

involving actual physical assault, (especially with weapons such as knives, infected

syringes, firearms and fists), and SAPOL and Star force assistance was evidenced by

nurses. Nurse [k] from Group 3 supported this finding by her statement: “I am still

affected by a siege which took place eighteen months ago.” This was also supported by

nurse [d] from Group 1 who stated: “I was so scared by the patient‟s sudden

unpredictability that I nearly peed myself.” All emergency nurses were dissatisfied with

the supply of security personnel and most nurses believed that Police should be situated

within the department since they represent law enforcement and therefore presented a

better chance for violence prevention. Nurse [c] in Group 1 supported this finding with

the following statement: “Security guards don‟t change anything because people don‟t

respect them because they have no power and if we had a Police Officer sitting in the

ED, maybe people might think twice.” Duress pendants and security guards were of no

real benefit as response was too slow and these measures made no impact on incidents

occurring. Aggression and violence training implemented by management did not allay

fears of and vulnerability to workplace violence. The majority of nurses strongly agreed

to relying on observation of „flags‟ on patients before deciding to approach them.

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(iii) Self-protection/remaining in the emergency field

This study found that a major source of concern for emergency nurses was the

perception of no foreseeable solution for protection from violence in the ED.

Participants resigned themselves to one day “burning out” or “getting injured” and that

every day before that occurred was a “bonus day”. In addition, with many nurses

coming and going, the dynamics of staff recruitment and retention only served to

“breakdown what remained of the cohesiveness of team morale” amongst the nursing

staff. The only perceived available means of survival from violence was the process of

„flagging‟. From the quantitative data, it is evident that most nurses (1) „flag‟ to protect

their colleagues from harm and (2) „flag‟ when violence is directed at them personally.

However, since „flagging‟ did not address violence in the ED it is no wonder that nurses

continued to feel unsafe and suffered the impacts of violence. Although all patient

behaviours from the two previous studies listed in the questionnaire, (Luck et al 2007;

Wilkes et al 2010), were „flagged‟, this study found that nurses were exposed to more

extreme experiences of violent patient behaviours such as “carrying of concealed

weapons” and “actual physical assault”.

Another finding from this study was the concern participants held regarding vital

information involving previous violent episodes by Mental Health patients not being

linked to HASS (Hospital Administration Software Service). Although HASS

accommodated the „flagging‟ process, this Mental Health violent patient information

was not linked and therefore not readily available to nurses. Therefore nurses could not

identify violent behaviour previously noted by other staff. Over 90% of nurses

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perceived that this patient information mattered to their safety as these patients

accounted for the majority of code blacks in the department.

5.4 Study Limitations/Strengths

Limitations to this study were; a brief three week period for the study, (a larger sample

population may have been gained given more time), reduced rates of retention in the ED, (a

recent loss of 25 senior emergency nurses over the last 10 months had occurred which may

have impacted on outcomes), and the majority of participants were shift workers, (possibly

deterring the delivery of information sessions/questionnaires and return of questionnaires).

In addition to these limitations, the department was overcrowded most days during the

study period and nurses were therefore under extreme pressure and possibly too busy to find

sufficient time to respond thoughtfully and/or accurately to items. Additional limitations

may have resulted in terms of the questionnaire design and formatting as well as selection

of focus group questions.

Strengths of this study were a good response rate (over 60%). Respondents were

interested in the subject material. Due to the use of a mixed methods approach a large

amount of qualitative participation occurred with numerous nurses being excited about

the prospect of participating in and contributing to the focus group interviews. The

study was well supported by divisional management.

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5.5 Recommendations for Further Investigation

The results from this study have important implications for the development of

strategies to reduce ED violence. New and innovative changes are needed to address

concerns that emergency nurses harbour concerning violence in the ED. Failure to

address these concerns serves to enhance danger. This study has shown that nurses

„flag‟ to keep themselves from harm and because „flagging‟ is a readily accessible

means of reporting violent patients who cause harm. Despite the availability of the

„flagging‟ process, „flagging‟ is not an established means of prevention of violence or a

deterrent from violence or a solution to violence. „Flagging‟ is a means by which nurses

alert themselves and each other to cues for potential violence which have been

identified. These „flags‟ make nurses hyper-vigilant when approaching „flagged‟

patients and give them cause to withdraw rapidly at the first sign of escalation of violent

behaviour. „Flagging‟ is a warning that potential for violence exists. It does not allay

fears or feelings of vulnerability amongst nurses to violence. In fact, it can be said that

„flags‟ put nurses on guard in preparation for conflict resulting in increased states of

nurse stress and patient marginalization. Therefore, more research needs to be

accomplished in order to establish if there are better tools than „flagging‟ or other better

methods of addressing ED violence. Reasons for violence existing in the ED and how it

can be prevented require ongoing investigation to assure nurses that they are protected

and safe while at work. It should not have to get to the stage where a nurse or anyone in

the ED suffers lifelong debilitation or loses their life as a result of workplace violence

stemming from unaddressed nursing concerns. The following associated

recommendations are made;

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Nurse managers/administrators accept reports of nurse experience of and

exposure to workplace violence to increase feelings of support and value among

nurses and increase opportunities to debrief.

Regular evaluation and feedback of nurse reports of violence to nursing staff

from nurse management are made to keep communication paths open and

realities of violence issues known.

Development of training programs for nurses for the use of the „flagging‟ of

violent patient process and the identification of cues for potential for violence.

Establishment and distribution of policy for the „flagging‟ of violent patients.

Creation of a link between knowledge of violent background of Mental Health

patients and the „flagging‟ process.

Consider the introduction of Police Officers within the emergency department to

uphold the law and improve feelings of safety for nurses and patients.

5.6 Conclusion

This study has revealed that 40% of the nursing participants in the study setting don‟t

„flag‟ and that most nurses, (whether they „flag‟ or not), had not cited a hospital policy

for „flagging‟. A specific criteria guiding recognition of patient-related cues for

identifying the need for „flagging‟ was not obtainable. In addition to this, formal

education was not received by staff members in relation to the „flagging‟ process or

reasons or benefits for „flagging‟.

105

„Flagging‟ may have been considered as a means of monitoring violence and

maintaining safety in the ED and therefore useful, but it was merely a warning

concerning the presence of violence in the ED and not a solution to violence.

Emergency nurses „flag‟ emergency patients in an effort to protect themselves and their

colleagues from harm from violent attack but „flagging‟ did not prevent the existence of

violence in the emergency department. Emergency departments are therefore unsafe

places in which to work despite the „flagging‟ process and reasons why nurses „flag‟

emergency patients.

Ongoing research into the use of tools for the identification of patient-related factors

concerning violence may assist to yield other perspectives of similar processes of

„flagging‟ and their outcomes. The recommendations implicate organisational level

changes for increased safety for emergency nurses. These recommendations are

generated by this study and thus considered to be important steps in the response to

workplace violence.

However, it is more than obvious from this study, that reliance on the process of

„flagging‟ for the protection of nurses against violent attack from emergency patients is

unsafe. It is also obvious that since „flagging‟ does not prevent the existence of violence

in the emergency department that emergency nurses are exposed to the accumulative

day-to-day negative physical and psycho-social effects of violence. Since „flagging‟ has

little impact on the existence of violence in the ED, or the reduction of risk of harm

from violence, future consideration of information yielded concerning the use of the

„flagging‟ process and reasons why nurses „flag‟ may be beneficial for the prevention of

violence in the workplace.

106

Since the need to „flag‟ emergency patients is loud and clear, it is at least obvious that

violence in the emergency department is an issue that needs to be addressed. The

question; „what is being done about why nurses are flagging emergency patients?‟ is

now generated.

Since nurses „flag‟ emergency patients to 1) declare danger and 2) attempt to prevent

harm, and since international efforts are currently being made to address the same issues

of violence in relation to „flagging‟, perhaps consideration could be given to the

introduction of policy which assists the protection of nurses by embracing legislation

which introduces assault of a nurse as a felony. Perhaps a worthwhile response to the

need and reasons for nurses „flagging‟ emergency patients is the consideration of the

implementation of policy for the prosecution of emergency nurse offenders. This

consideration may assist in increasing rates of emergency nurse safety, emergency nurse

retention and best patient outcome. Further research needs to occur therefore to

establish effective responses to reasons why nurses feel the need to protect themselves

from harm from violent patients.

Further study into this phenomenon is recommended, as well as changes in emergency

nurse knowledge and understanding of young adolescent males who present for

treatment of wounds sustained in interpersonal violence activity.

107

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APPENDICES

124

Appendix 1: Aggression and Violence Incident Report Form (IF 18) page 1

125

Appendix 1: Aggression and Violence Incident Report Form (IF 18) page 2

126

Appendix 1: Aggression and Violence Incident Report Form (IF 18) page 3

127

Appendix 1: Aggression and Violence Incident Report Form (IF 18) page 4

128

Appendix 2: Research Questionnaire

113

RESEARCH QUESTIONNAIRE:

WHY DO NURSES ELECTRONICALLY CHART VIOLENCE ALERTS ON, (OR ‘FLAG’), EMERGENCY PATIENTS?

‘FLAGGING’: A TERM USED FOR HIGHLIGHTING A PATIENT WHO EXHIBITS PREDICTIVE CUES FOR VIOLENT BEHAVIOR OR WHO IS THREATENING WORKPLACE SAFETY IN THE EMERGENCY DEPARTMENT VIA THE IMPLEMENTATION OF ELECTRONIC CHARTING FOR NURSES USING EDIS, (FORMERLY HASS).

THIS SURVEY AIMS TO BETTER UNDERSTAND WHY NURSES FLAG PATIENTS IN THE ED AND WILL TAKE APPROXIMATELY 15-20 MINUTES TO COMPLETE.

[Type the document

title] WHY DO NURSES FLAG EMERGENCY PATIENTS AS A

THREAT TO WORKPLACE SAFETY?

[Type the author name] [Type the company name] [Pick the date]

114

PLEASE REMOVE THIS FORM AND KEEP IT FOR YOUR RECORDS.

WHY DO NURSES ELECTRONICALLY CHART VIOLENCE ALERTS ON, OR ‘FLAG’, EMERGENCY PATIENTS?

PARTICIPANT INFORMATION SHEET Dear colleague,

My name is April Stanley-Banks. I am an emergency nurse with a keen interest in violence in the ED and the associated nurse decision to ‘FLAG’ patients on EDIS, (Emergency Department Information Service), (formerly HASS, ((Hospital Administration Software Service)), the ED electronic patient tracking system. I intend to conduct a study on why nurses ‘flag’ patients using a survey questionnaire and focus group interviews. This research is being conducted for a Masters of Nurse Practitioner at the University of Adelaide. Participation I am inviting you to participate in this research study by completing the attached questionnaire. Your participation is voluntary. You are free to withdraw your participation at any time without prejudice.

The survey population The target population for this research is all nurses who work in the Lyell McEwen Hospital ED, including Line and Divisional Nurse Managers and Duty Nurse Coordinators. Aims of the study The aim of this research is to better understand why nurses ‘flag’ patients. Commitments It will take approximately 15-20 minutes for you to complete the research questionnaire. Completion and submission of the questionnaire indicates your consent to participate in the study. If you wish to take part in the focus group interviews, which will be undertaken in July 2011, please feel free to fill in the ‘Willingness to Participate’ form over leaf, detach it from the questionnaire and return it to the questionnaire collection box for completed surveys. Possible benefits of the research Data collected from this research will provide a better understanding of what patient and nurse related factors are associated with ‘flagging’ and contribute to the body of knowledge surrounding meanings of violence attributed by ED nurses and reporting of workplace violence. Confidentiality / Ethical Considerations This research study is anonymous. All records containing personal information will remain confidential and no information which could lead to your identification will be released. Any potential identifying data will not be used in the reporting of this research. This research project has received appropriate University of Adelaide and Adelaide Health Service Research Ethics Committee (TQEH/LMH/MH) approval. Should you wish to speak to a person not directly involved in the study in relation to:

matters concerning policies,

information about the conduct of the study,

your rights as a participant,

or should you wish to make a confidential complaint, you may contact the Executive Officer of The Adelaide Health Service Human Research Ethics Committee, on (08) 8222 6841. Alternatively, should you have any questions please contact the chief investigators below and/or the University of Adelaide Human Ethics Committee Secretary on (08) 8303 6028. Dr Timothy Schultz Tiffany Conroy April Stanley-Banks Technical Director Lecturer Clinical Nurse Australian Patient Safety Foundation Discipline of Nursing Emergency Department University of Adelaide Lyell McEwin Hospital Phone 8303 3091 Phone 8303 6290 Phone 8523 2579 Email: tim.schultz@adelaide.edu.au Email: tiffany.conroy@adelaide.edu.au Email: aba22181@bigpond.net.au

PLEASE DETACH THIS FORM AND RETURN IT SEPARATELY TO

THE QUESTIONNAIRE COLLECTION BOX.

115

WILLINGNESS TO PARTICIPATE IN FOCUS GROUP INTERVIEWS FORM

If you are interested in participating in the research focus group interviews, please fill in this form, detach

from the questionnaire and return separately to the questionnaire collection box in the staff tea room no later

than 18th February 2011.

I,………………………………………………………………………………………………………(please print name)

am willing to take part in the focus group interviews held for the research project entitled ‘WHY DO NURSES

ELECTRONICALLY CHART VIOLENCE ALERTS ON, OR ‘FLAG’, EMERGENCY PATIENTS?’.

I can be contacted by the researcher by: email;………………………………………..,……………………………

mobile;………………………………….....in order to be informed of the date, place and time of the interviews.

I understand that there may be potentially more participants than is required and that my willingness to

participate should be expressed as early as possible.

………………………………………………………………………………………………………………………………

(signature) (date)

116

WHY DO NURSES ELECTRONICALLY CHART VIOLENCE ALERTS ON, OR ‘FLAG’, EMERGENCY PATIENTS?

This survey aims to better understand why nurses flag patients in the ED and will take approximately 15 – 20 minutes to complete.

‘FLAG’ …………THE ELECTRONIC IMPLEMENTATION OF A VIOLENCE

ALERT ON A PATIENT BY ED NURSES.

‘EDIS’ …………EMERGENCY DEPARTMENT INFORMATION SERVICE.

‘HASS’ …………HOSPITAL ADMINISTRATION SOFTWARE SERVICE.

SECTION A: NURSE- RELATED FACTORS

SECTION A1: DEMOGRAPHICS

A1.1 What is your age?

Mark ONE answer by ticking the appropriate shaded box:

<20years 21-30years 31-40years 41-50years 51-60years >61years

A1.2 What is your gender?

Mark ONE answer by ticking the appropriate shaded box:

male female

A1.3 What is your current position?

Mark ONE answer by ticking the appropriate shaded box:

Enrolled Nurse Emergency Department Liaison Nurse

Enrolled Nurse Diploma Associate Clinical Service Coordinator

Enrolled Nurse Advanced Diploma Clinical Nurse Specialist

Registered Nurse Level 1 Role

Progression

Duty Nurse Coordinator

Registered Nurse Level 2 Role

Progression

Nurse Practitioner Candidate

Registered Nurse Level 3 Role

Progression

Clinical Service Coordinator

Clinical Nurse Nurse Practitioner

Emergency Educator Divisional Nurse Manager

A1.4 How long have you worked in your current position?

Mark ONE answer by ticking the appropriate shaded box:

<6months 6-12months 12-18months

2-5years 5-10years >10years

A1.5 How long have you worked in the emergency field?

Mark ONE answer by ticking the appropriate shaded box:

117

0-2years 6-10years

3-5years >10years

A1.6 How long have you worked in your current location?

Mark ONE answer by ticking the appropriate shaded box:

0-2years 6-10years

3-5years >10years

A1.7 Are you Aboriginal or Torres Straight Island descent?

Mark ONE answer by ticking the appropriate shaded box:

yes no

A1.8 Are you overseas trained?

Mark ONE answer by ticking the appropriate shaded box:

yes no

A1.9 What shifts do you work?

Tick ONLY ONE of the three shaded boxes in each of the row selections below:

Full time permanent Part time permanent Casual

Tick ONLY ONE of three shaded boxes below:

All shifts Day shifts only Night shifts only

Tick ONLY ONE of the three shaded boxes below:

Seven day roster Monday to Friday only Weekends only

A1.10 What is your highest qualification?

Mark ONE answer by ticking the appropriate shaded box:

Certificate of Enrolled Nursing Post Graduate Certificate

Diploma of Enrolled Nursing Post Graduate Diploma

Advanced Diploma of Enrolled

Nursing

Masters

Bachelor of Nursing Doctorate

A1.11 Are you currently studying? Mark ONE answer by ticking the appropriate shaded box:

Yes Go to A1.2 No Go to Section A2.1

A1.12 What is your level of current study?

Mark ONE answer by ticking the appropriate shaded box:

Enrolled Nurse Diploma Post Graduate Diploma

Enrolled Nurse Advance Diploma Masters

Post Graduate Certificate Doctorate

118

SECTION A2: FLAGGING

A2.1 Have you ever flagged a patient in the ED? Mark One answer by ticking the appropriate

shaded

box:

No Go to A2.2 Yes Go to A2.3

A2.2 If you have NEVER flagged a patient in the ED, why not?

Mark ALL answers which apply by marking the appropriate shaded boxes below:

Unaware of flagging process The patient is not responsible for actions

Too busy to flag Fear of managerial retaliation post flagging

Don’t know how to flag Perpetrator was provoked by staff

Uncertain of flagging criteria Too distressed to flag post incident

Have not experienced an incident serious

enough to flag

Patient is aiming aggression at hospital,

not me

Too many incidents to flag The patient has been flagged previously

I am not senior enough to flag The patient’s presentation is legitimate

Other – expand below:

Other reasons for not flagging – please elaborate in detail below. Then go to B1.2.

A2.3 If you HAVE flagged a patient in the ED, how FREQUENTLY have you flagged?

Mark ONE answer by ticking the appropriate shaded box:

Greater than or equal to once a shift Once every six months

Once a week Once a year

Once a month Less than once a year

A2.4 If you HAVE flagged a patient in the ED, how LONG AGO did you last flag?

Mark ONE answer by ticking the shaded appropriate box:

In the last 24 hours In the last six months

In the last week In the last 12 months

In the last month Greater than 12 months ago

119

SECTION B: PATIENT- RELATED FACTORS

B1.1 Of the listed patient behaviors below

which………………….

Mark your answers by ticking each of the appropriate boxes.

… HAVE

you

EVER

‘flagged’?

..WOULD

you

ALWAYS

‘flag’?

..WOULD

you

NEVER

‘flag’?

Threat of harm

Aggressive statements or threats

Intimidation

Clenched fists

Resisting health care

Prolonged or intense glaring at nurse

Name calling

Yelling

Increase in volume (speech)

Irritability

Walking back and forth to nurses’ area

Walking around confined areas such as waiting room or bed

space

Sharp or caustic retorts

Demeaning inflection (pulling faces)

Belligerence

Demanding attention

Humiliating remarks

Others – please specify below and tick appropriately below.

Example: threat with bloody syringe X

Example: yelling + threat to harm + name calling all together X

120

SECTION B: PATIENT- RELATED FACTORS

B1.2 Which THREE of the listed patient behaviors below would you MOST LIKELY flag?

Tick THREE responses ONLY.

Threat of harm

Aggressive statements or threats

Intimidation

Clenched fists

Resisting health care

Prolonged or intense glaring at nurse

Name calling

Yelling

Increase in volume (speech)

Irritability

Walking back and forth to the nurses’ area

Walking around confined areas such as waiting rooms or bed space

Sharp or caustic retorts

Demeaning inflection (pulling faces)

Belligerence

Demanding attention

Humiliating remarks

Others – please elaborate below:

121

SECTION C: NURSE ATTITUDES, PRACTICE AND KNOWLEDGE OF ‘FLAGGING’ IN THE ED

NURSE ATTITUDES TOWARDS ‘FLAGGING’

Please tick one box to indicate your answer.

Strongly

Disagree

Disagree

Neither

Agree or

Disagree

Agree

Strongly

Agree

C1.1 Patients who direct violence at me personally should

always be flagged.

C1.2 Patients who direct violence at the hospital system

should always be flagged.

C1.3 Violent patients who may not be responsible for their

behavior due to illness should always be flagged.

C1.4 Violent patients whose illness affects their self- control

should always be flagged

C1.5 I am more likely to flag a patient if their presentation to

ED is illegitimate.

NURSE PRACTICES OF ‘FLAGGING’ Please tick one box to indicate your answer.

Strongly

Disagree

Disagree

Neither

agree

nor

Disagree

Agree

Strongly

Agree

C1.6 I flag to help reduce the trajectory of violence in the ED.

C1.7 I flag to help protect my work colleagues.

C1.8 I flag to equip ED nurses against violent patients.

C1.9 flagging makes me feel safer in the ED.

C1.10 I always observe violence alerts on flagged patients

before approaching them.

NURSE KNOWLEDGE OF FLAGGING Please tick one box to indicate your answer.

Yes

No

Don’t know

C1.11 Is there a hospital policy for patient flagging?

C1.12 Is there a process for removing a flag from a patient’s

record?

C1.13 Have you ever removed a flag from a patient’s record?

C1.14 Would you ever remove a flag from a patient’s record?

122

SECTION D: NURSE PERCEPTION OF FLAGGING IN THE ED

Please elaborate your answers to the following open-ended questions:

D1.1 Is flagging a part of the nursing duty of care? Mark one answer by ticking the appropriate

shaded box.

Yes No

Why?………………………………………………………………………………………………………………………

…..….………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………………

………….…………………………………………………………………………………………………………………

D1.2 Do you agree that violence flags already placed on patients should ever be removed? Why?

………………………………………………………………………………………………………………………………

…..…………………………………………………………………………………………………………………………

………..……………………………………………………………………………………………………………………

……………....………………………………………………………………………………………………………………

D1.3 Does experience gained with exposure to violence cause you to flag less or more?

Mark one answer by ticking the appropriate shaded box.

Less More

Why?…………………………………………………………………………………………………………….…………

….…………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………………

D1.4 Have you ever used an Aggression/Violence Report Form IF18 to report a violent incident in

which you have been involved? Mark one answer by ticking the appropriate shaded box.

Yes No

If yes, did you flag the patient involved on EDIS as well? Why? ………………………………………………

………………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………………

D1.5 Do you feel that patient information regarding violent history known by the ED Mental Health

team should be linked to the EDIS, (flagging) system? Mark one answer by ticking the appropriate

box below.

Yes No

Why?…………………………………………………………………………………………………………….…………

…..……………………..……………………………………………………………………………………………………

……….…………………………………………………………………………………………………………..…………

………………………………………………………………………………………………………………………………

D1.6 How does an existing flag influence your interaction with that patient? ………………………………………………………………………………………………………………………………

.......................................................................................................................................................………….......

………………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………………

………………………………………………………………………………………………………………………………

THANKYOU FOR COMPLETING THIS QUESTIONNAIRE.

125

Appendix 3: Focus Group Interview Questions

1. How effective do you think security is in the emergency department

against violent patients?

2. Do you feel that toleration to violence is an expected part of your

job?

3. Are you equipped to deal with violence at work?

4. Does experience of and exposure to workplace violence impact on

you personally?

5. Are you supported by management in relation to workplace

violence?

126

Appendix 4: ED Violence Incidents Data

127

Appendix 4: ED Violence Incidents Data

128

Appendix 4: ED Violence Incidents Data

129

Appendix 5: Newspaper Articles

The Advertiser August 30

th

2011 p3

130

Appendix 5: Newspaper Articles

1. Sunday Mail August 27th

2011 p5 2. Messenger News February 15

th

p1 3. Messenger News February 15

th

p10

131

Appendix 5: Newspaper Articles

1. Messenger News 15th

February 2011 p29 2. News Review Messenger 16

th

February 2011 p1

132

Appendix 5: Newspaper Articles

Sunday Mail 6

th November 2011 p9

133

Appendix 6: Advertisement for Survey Participant Recruitment

134

Appendix 7: Willingness to Participate in Focus Group Interview Form

PLEASE DETACH THIS FORM AND RETURN IT SEPARATELY TO THE QUESTIONNAIRE COLLECTION BOX.

WILLINGNESS TO PARTICIPATE IN FOCUS GROUP INTERVIEWS FORM

If you are interested in participating in the research focus group interviews, please fill in this

form, detach from the questionnaire and return separately to the questionnaire collection box

in the staff tea room no later than 18th February 2011.

I,………………………………………………………………………………………………………….(please print name)

am willing to take part in the focus group interviews held for the research project entitled

‘WHY DO NURSES ELECTRONICALLY CHART VIOLENCE ALERTS ON, OR ‘FLAG’, EMERGENCY

PATIENTS?’.

I can be contacted by the researcher by: email;…………………………………………..,…………………………

mobile;……………………………………….....in order to be informed of the date, place and time of the

interviews.

I understand that there may be potentially more participants than is required and that my

willingness to participate should be expressed as early as possible.

…………………………………………………………………………………………………………………………………..

(signature) (date)

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Appendix 8: Participant Information Sheet

PLEASE REMOVE THIS FORM AND KEEP IT FOR YOUR RECORDS.

WHY DO NURSES ELECTRONICALLY CHART VIOLENCE ALERTS ON, OR ‘FLAG’, EMERGENCY PATIENTS?

PARTICIPANT INFORMATION SHEET

Dear colleague,

My name is April Stanley-Banks. I am an emergency nurse with a keen interest in violence in the ED and the associated nurse decision to ‘FLAG’ patients on EDIS, (Emergency Department Information Service), (formerly HASS, ((Hospital Administration Software Service)), the ED electronic patient tracking system. I intend to conduct a study on why nurses ‘flag’ patients using a survey questionnaire and focus group interviews. This research is being conducted for a Masters of Nurse Practitioner at the University of Adelaide.

Participation

I am inviting you to participate in this research study by completing the attached questionnaire. Your participation is voluntary. You are free to withdraw your participation at any time without prejudice.

The survey population

The target population for this research is all nurses who work in the Lyell McEwen Hospital ED, including Line and Divisional Nurse Managers and Duty Nurse Coordinators.

Aims of the study

The aim of this research is to better understand why nurses ‘flag’ patients.

Commitments

It will take approximately 15-20 minutes for you to complete the research questionnaire. Completion and submission of the questionnaire indicates your consent to participate in the study. If you wish to take part in the focus group interviews, which will be undertaken in July 2011, please feel free to fill in the ‘Willingness to Participate’ form over leaf, detach it from the questionnaire and return it to the questionnaire collection box for completed surveys.

Possible benefits of the research

Data collected from this research will provide a better understanding of what patient and nurse related factors are associated with ‘flagging’ and contribute to the body of knowledge surrounding meanings of violence attributed by ED nurses and reporting of workplace violence.

Confidentiality / Ethical Considerations

This research study is anonymous. All records containing personal information will remain confidential and no information which could lead to your identification will be released. Any potential identifying data will not be used in the reporting of this research. This research project has received appropriate University of Adelaide and Adelaide Health Service Research Ethics Committee (TQEH/LMH/MH) approval.

Should you wish to speak to a person not directly involved in the study in relation to:

matters concerning policies,

information about the conduct of the study,

your rights as a participant,

or should you wish to make a confidential complaint,

you may contact the Executive Officer of The Adelaide Health Service Human Research Ethics Committee, on (08) 8222 6841. Alternatively, should you have any questions please contact the chief investigators below and/or the University of Adelaide Human Ethics Committee Secretary on (08) 8303 6028.

Dr Timothy Schultz Tiffany Conroy April Stanley-Banks

Technical Director Lecturer Clinical Nurse

Australian Patient Safety Foundation Discipline of Nursing Emergency Department

University of Adelaide Lyell McEwin Hospital

Phone 8303 3091 Phone 8303 6290 Phone 8523 2579

Email: tim.schultz@adelaide.edu.au Email: tiffany.conroy@adelaide.edu.au Email: aba22181@bigpond.net.au

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Appendix 9: Research Proposal, page 1

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Appendix 9: Research Proposal, page 2

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Appendix 9: Research Proposal, page 3

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Appendix 9: Research Proposal, page 4

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Appendix 9: Research Proposal, page 5

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Appendix 9: Research Proposal, page 6

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Appendix 9: Research Proposal, page 7

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Appendix 9: Research Proposal, page 8

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Appendix 10: University of Adelaide Ethics Committee Approval

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Appendix 11: CNAHS Ethics Approval/Hospital Setting Willingness to Support

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Appendix 11: CNAHS Ethics Approval/Hospital Setting Willingness to Support

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Appendix 12: Pilot Questionnaire, page 1

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Appendix 12: Pilot Questionnaire, page 2

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Appendix 12: Pilot Questionnaire, page 3

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Appendix 12: Pilot Questionnaire, page 4

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Appendix 12: Pilot Questionnaire, page 5

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Appendix 12: Pilot Questionnaire, page 6

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Appendix 12: Pilot Questionnaire, page 7

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Appendix 12: Pilot Questionnaire, page 8

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Appendix 12: Pilot Questionnaire, page 9

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Appendix 13: Australian Nursing Federation Policy, page 1

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Appendix 13: Australian Nursing Federation Policy, page 2

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Appendix 13: Australian Nursing Federation Policy, page 3

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Appendix 13: Hospital Policy, Personal Threat Action Card 1

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Appendix 13: Hospital Policy, Personal Threat Action Card 2

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Appendix 13: Hospital Policy, Personal Threat Action Card 3

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Appendix 13: Hospital Policy, Personal Threat Action Card 4

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Appendix 13: Hospital Policy, Personal Threat Action Card 5

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Appendix 13: Hospital Policy, page 1 of 3

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Appendix 13: Hospital Policy, page 2 of 3

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Appendix 13: Hospital Policy, page 3 of 3

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Appendix 14: Participant Response to Item B1.2

I would be most likely to flag patients which have actually struck nursing staff &

caused bodily harm.

Spitting, lunging, throwing items, scratching, biting, pulling hair.

I would flag anyone threatening safety by use of bomb/explosive device in or

around the department.

Concealment of weapons/carrying weapons.

Any patient requiring multiple code blacks.

Star force involvement/siege.

Patient threatening to kill other patients in the waiting room.

Patient with HIV threatening to spray me with blood.

Patient chased me with a screwdriver and I had to run to safe area.

I found a patient trying to hang themselves in the toilet.

Patients punching nurses.

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Appendix 15: Focus Group In-House Nurse-to-Nurse Discussions

Discussion 1:

Group 2, (f): The thing with this training is you‟ve got this big need to be trained, and

it‟s like with the protocol with the STEMI or a code stroke – you must know everything

to the ninth degree. But, when you look at people‟s recall at what was taught, they can‟t

tell you anything coz a lot of it is about how committed you are to taking this stuff on

board. It amazes me how whether it is the way the training is delivered, or for whatever

reason, people are not coming away with enough to make them feel safer.

Group 2, (g): You need to give people the skills to recognise and cope better with

violence.

Group 2, (f): Who taught you about what‟s important about a cardiology patient?

Group 2, (g): Most of what I have learnt is from being on the job.

Group 2, (f): You sought it out didn‟t you?

Group 2, (g): Yes.

Group 2, (f): For some reason I hear all the time, „I haven‟t been taught‟. You need to

find it out for yourself.

Group2, (g): But, aggression and violence is not a part of what we‟re all brought up to

believe. So why would we source out something that‟s going to be stressful to us? You

go into nursing to heal, to help the sick people and it‟s not a part of nursing that you‟re

going to be spat on, abused and slapped. It‟s just not a part of life in general. If you‟re

living in an abusive relationship, like child abuse, you can‟t get out of it. But, when

you‟re an adult in a bad relationship, you can go. If you want to leave emergency

nursing then that‟s fine. But, it‟s not a part of life that we‟re brought up to believe is

right. It‟s just not acceptable. Why would I go and learn karate? Violence is not a part

of what life is about.

Group 2, (f): You just said that it is.

Group 2, (g): Here at work. I don‟t have to try and get out of violent situations like

running across the street to get away from my husband or children or grandchildren –

there‟s just no violence there. I want to learn things about healing. You want to be a

nurse which means healing, compassion, empathy. But, the people that you treat won‟t

allow you to.

Group 2, (f): There is a contradiction in your perception of what a nurse is and what

nursing really is.

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Appendix 15: Focus Group In-House Nurse-to-Nurse Discussions (continued)

Group 2, (g): Nursing is changing. You go to a course to learn how to give medications.

You don‟t think you go to a course to learn how to defend yourself. Part of the nursing

uniform should be a stun gun or Taser. Before I came into nursing I didn‟t think I would

need to source solutions for protection from violence. I guess it was naïve of me and I

realize that I need to develop coping mechanisms.

Group 3, (i): You feel obligated to do your nursing assessment of violent patients.

Group 3, (l): Oh no, I don‟t. If I know that a person is violent, I won‟t. I don‟t care. I

refuse to go in the cubicle.

Group 3, (i): But somebody has to.

Group 3, (l): No they don‟t.

Group 3, (i): You just can‟t leave a patient in a cubicle unattended.

Group 3, (l): Yes you can. If they are aggressive – yes. I don‟t believe you have to go in

at all. No way. Why would you put yourself in a situation where you could be punched

or kicked or shoved just to do an assessment? If he‟s walking around and he‟s got an

airway then that‟s okay. The only time you would go in is if he dropped to the floor and

you were able to manage him.

Group 3, (i): So you‟re saying if the patient‟s aggressive for 3/24 and something else

could be going on, you wouldn‟t intervene, or do anything. You would just stand back

and look at them?

Group 3, (l): I would wait until they were going to call a code black, have the proper

team there, to put him under control, and then I would do my assessment. Because, I‟m

not going in while he‟s violent and throwing things around. You can‟t even do an

assessment if he‟s violent.