Workplace violence faced by nurses in the accident and emergency department leads to anxiety

Violence in the workplace faced by the nurse is a major issue worldwide and is increasing at a high rate. Its prevalence is noted by various studies that reflect its severity. The research by Ramacciati et al. (2018) has conducted a qualitative study with the aim to investigate violence against the emergency nurse. They included 15,1628 emergency nurses employed in 668 different Italian National Health Service Accident and Emergency Departments. 39 items questions-based interview was conducted included them for 1 year, among which 1100 nurse responded to the survey and 265 was active in focus questions. The survey analysis noted that all the nurses were having experience of approx. of 11-42 years and all of them have undergone the issue of workplace violence. Similarly, another research by Hassankhani et al. (2019) included 16 nurses from different five hospitals in Iran for the semi-structured interview. Although the sample size in the study was low, however, all the different nurses from the different hospitals have experienced workplace violence. It indicates the situation of workplace violence is highly common and prevalent in the emergency department. To support the above finding, the outcome is also evident from the research of Bernaldo-De-Quirós et al. (2015), who undertook a retrospective cross-sectional study including emergency service from 70 different care units in the Madrid region. It included 441 healthcare professionals that comprised of 135 physicians, 179 emergency care assistants and 127 nurses. On investigation related to the psychological issue faced in response to workplace violence, it was noted that approx. 76% of the participants have encountered workplace violence or observed it happening. Therefore, it explicitly explains that workplace violence is highly prevalent worldwide and there is the need to take immediate step to mitigate the issue.

Another research by Alyaemni and Alhudaithi (2016) has undertaken a cross-sectional study in the three-emergency department of Riyadh. There was total participation of the 171 nurses including 100 females and 71 males. They all have less than 5 years of experiencing. It noted that 80 participants have experienced workplace violence in less than 12 months, and the rest have encountered the verbal abuse in five years which is yet early when compared to the number of years of experience. Another similar study by Talas Kocaöz and Akgüç (2011) highlight the high incidence of violence in the emergency department. The researcher has conducted a descriptive study which included 270 staffs working in an emergency based in turkey. They all were interviewed with 36 items questions where the outcome showed that 85.3% of participants have encountered a minimum of one type of workplace violence.

It is more devasting to note that the experience of workplace violence is so frequent that they regard it as part of life and have been used to it. Some nurse take is as part of the job. It is also evident from a study of Ramacciati et al. (2018) where 428 nurses responded workplace violence as the part of duty and 247 nurses responded that since there is the solution to the issue of the violence, they have been used to it. Thus, it shows the most serious issue of the high prevalence of workplace violence in the emergency department. The high incidence of workplace violence has always been an ignored issue. The analysis of the review found that workplace of violence is common worldwide however, there is no evidence noted that can note the prevalence of the workplace in Singapore, indicating a lack of research in Singapore.

Type of violence in the workplace

The workplace violence faced by the healthcare professional is characterized by verbal abuse, physical abuse and discrimination. The research by Pich, Hazelton and Kable (2013) has conducted a qualitative study that investigated the experience of the Australian nurses working in the emergency department particularly with the young adult patients and parents of the paediatric patient. Semi-structured interview with the nurses noted that they mainly encountered physical and verbal abuse including threats and swearing. They also reported that it was the daily issue encountered while caring for young adults’ patients. Nevertheless, the situation can be frightening and dangerous as some of the nurses may become injured by the attack of young adults. It was noted that 11 participants added the usage of opportunistic items and traditional weapons to intimate the nurses. The consequence noted broken nose, wrist injury, damage of ligaments and breaking of thumbs. Thus, it can be said that physical violence was mainly perpetrated by the parents of the paediatric patient in the emergency department, however, such incidence was noted to be intentional or personal.

Compared with the research of Ramacciati et al. (2018), physical and verbal abuse was found by the common type of encountered violence. Another study Lau, Magarey and Wiechula (2012) also noted that aggressive behaviourof patients is highly prevalent in the emergency department. The most serious issue noted while caring for the young adult (Pich, Hazelton & Kable, 2013). The reported that they threaten them, chased, broke the window and abuse as an act of aggression. Although it is known to leave the nurse frightening and shaken regarding the situation, verbal abuse is potentially more serious as it used to be personal.

The study by Talas Kocaöz and Akgüç (2011) has found that 82.5% have faced workplace violence in the emergency department, among which 41.1% encountered physical assault, 55.5% verbal threats, 79.6% verbal abuse and 15.9% sexual harassment. Similarly, the cross-sectional survey by Alyaemni and Alhudaithi (2016) has also found that 80 nurses have faced verbal abuse, 20 have encountered physical and verbal violence. The study noted that gender and educational qualification was the major factor linked with the type of violence. Furthermore, the healthcare professional reported that verbal abuse and verbal threats mainly comes from the relatives of the patients and other visitors. It is noted in the research of Alyaemni and Alhudaithi (2016) that 82.4% cases involving patients and 64.8% cases involving relatives and visitor were the common instigator of the workplace violence in the emergency department. In support of thatLau, Magarey and Wiechula (2012) have noted that due to the uncontrolled situation in the emergency, the aggressive attitude of the relative is common and most prevalent.

Most of the healthcare professional reported that most disrespectful type of workplace violence comprises of the threats made by relatives with a combination of weapons like a knife as they approach the nursing staffs. It is noted that such a situation is highly prevalent at the time of the end of visiting hours when the nurse requested them to leave. A survey and interview with the nurse by Hassankhani et al. (2019) have found that some of the nurses have experienced verbal threats from the relatives saying they know where they live and look for them after their shift hours. This makes them feel unsafe in the healthcare environment.

The rationale for workplace violence

Workplace violence is prevalent due to numerous reasons. The literature search has noted several studies that found the cause of workplace violence. Ramacciati et al. (2018) has noted the precipitating factors that trigger workplace violence. It noted that the weak communication skill of the nurse makes the patient irritated as they are unable to understand the issue. The response by 578 nurses noted that due to the poor communication of the nurses and patient, the act of violence is high prevalence. The survey also noted that 818 nurses responded that some of the conflicts arise between the nurse and patient due to the different perspective of unsuitable use of the emergency department for non-urgent patients. This makes the relative disrespected and gives rise to verbal abuse. The research has also noted that discriminating nurse on the basis of the job makes them more vulnerable to workplace violence. On interview, the nurses noted that they are not respected like doctors and their profession allow the patients to behave badly. Thus, the poor manner, behaviour, attitude, and lack of quality respect for the work of the nurse are the other major reason for workplace violence including verbal abuse and physical abuse.

The finding is supported by Lau, Magarey and Wiechula (2012), where the researcher also noted that cultural and social factors are the other trigger of the violence in the emergency department. The researcher conducted an ethnographic study in two parts to investigate the violence in the emergency department. The result of the investigation was done thematically. It found that some of the nurses responded that due to the difference in the cultural background and some with the low socioeconomic background as verbally abused from the patients and relatives. Apart from it, the study has noted that waiting time and ignorance of request by the nurses are the triggering point when the patient becomes violent and aggrieve. The issue of large waiting time is also reported by Ramacciati et al. (2018); Alyaemni and Alhudaithi (2016); and the second part of an investigation by Lau, Magarey and Wiechula (2012).

The high prevalence of workplace violence is also due to the lack of organizational management and working guideline. As reported by Hassankhani et al. (2019) nurse responded that there is no working guideline in the healthcare sector that could solve the issue of workplace conflict between the nurse and patient or nurse or relatives. The healthcare professional despite having access to online education, they are ignorant about what needed to be done at the time of violence. The finding can be compared with the study by Alyaemni and Alhudaithi (2016) where the participants also reported that in the issue of workplace violence, healthcare management does not take any mitigation step. The finding stated that physical assaults and verbal threats experienced by the nurse were not reported by the manager and incidence estimated to be 43.2% and 65.3% respectively. Thus, this indicates that the poor administrative factor in the healthcare system gives rise to workplace violence involving verbal and physical abuse. The aforementioned study has also noted another reason for the workplace violence which included a lack of reporting of the incidence. The nurse said that as there is no action taken against the violence, the nurses are least considered to report the violence to the head of the administration. The outcome is congruent with the finding of Bernaldo-De-Quirós et al. (2015) and TalasKocaöz and Akgüç (2011).

Experience and consequence following workplace violence

According to the recent review, the high incidence of workplace violence against the nurses has caused them to experience verbal abuse, physical violence and others. The study by Alyaemni and Alhudaithi (2016) has found that with the prevalence of workplace violence is noted with a negative effect on the nurses. It highlighted that workplace violence not only physically harms the nurse; it poses a huge psychological impact. Alyaemni and Alhudaithi (2016) stated that nurses received violence from the security officers and housekeepers. The reactions that occurred was anger and sadness. The nurses stated that they could not do anything to solve the issue and it posts a huge burden in the work that outcome with stress and anxiety. Compared with the finding of Bernaldo-De-Quirós et al. (2015) where total nurse participants were 441. Majority of the healthcare professional has been exposed to the violence like physical and verbal abuses and significantly there was the large number of nurses presented with mental illness like depression, anxiety, burnout syndrome and emotional exhaustion and depersonalization. The nurse reported that the frequency of the workplace violence was too recurrent in the emergency department, that leads to anxiety and emotional exhaustion five times more than in normal situation. They also noted that physical aggression is the main type of violence that lead to anxiety whereas verbal aggression causes burnout syndrome. Therefore, it indicates that workplace violence is becoming the major cause of high poor mental status.

The above research is congruent with the study of Hassankhani et al. (2019) where the consequence of workplace violence among the nurses has been studied. The study found that suffering nurse reported mental health risk, physical health risk, the threat to social and personal integrity. Focusing on the mental health risk, the nurse noted suffering from anxiety, unpleasant emotions, depression and stress. Majority of the nurse talked about anxiety following workplace violence. Apart from it, the nurse also reported that due to the mental illness they also experience physical health issues like gastrointestinal problem and headaches. It also highlighted the victim of workplace violence, low interest in the work, medical error, poor patient care and job dissatisfaction. Therefore, the research explicitly noted that due to workplace violence, both patient and nurse are negatively impacted.

Workplace violence against nurses is a major contributor to work stress and mental illness. The literature has also highlighted another evidence for the adverse reaction of the violence among the nurses. The study by Ramacciati et al. (2018) has undertaken a thematic analysis of the finding. Among the themes, the consequence of workplace violence has addressed the mental illness faced by the nurse. It noted that some nurses feel alone and frustrated as they are not supported in the healthcare organization. They also said that no one does consider the severity of the issue. They feel that workplace violence is their personal issue. All such thought makes them mentally ill and leads them to suffer from stress, anxiety and depression. It also noted that most of the workplace violence takes place in the accident and emergency department which is the major reason for the high rate of burnout and anxiety. Due to the lack of focus on the issue, the incidence of workplace violence has tremendously increased. When the finding was compared with the outcome of the Pich, Hazelton and Kable (2013), it noted that feeling of unsafe in the working environment due to the violence leads to huge stress and anxiety. They fear being physically assaulted or disrespected. The research found that 50% of nurses have experienced physical violence and feel unsafe. They narrated that the aforementioned issue leads them to depression and they are unable to work with maintaining the standard of practice. Thus, the care of the patients is sometimes compromised. The prevalence of workplace violence leading to stress and anxiety with other related issue is evident from all the gather literature research.

Workplace violence expectable but not prevented

The healthcare professional refers to workplace violence as the daily situation which is not completely prevented. The incidence and frequency of the physical and verbal abuse have risen at a high rate that all the mitigation steps if taken, does not achieve success. When attending the patient in the accident and emergency department, the nurses explained that verbal abuse and aggression is expected at larger extend.Hence, the nurse uses to be careful about the behaviour of the patients. It is noted in the research of TalasKocaöz and Akgüç (2011) that early signs of the aggressive attitude of the patient with alcohol abuse or drug abuse are recognised by the nurses as they tend to turn irritated, act angrily and become violent during the care or medication administration. In such a situation, the nurses emphasised the significance of the not escalating the issue for example they provide medication that could relax the patients. However, the follow up is not recognised that make the nurse more vulnerable to the situation of violence.

Despite the fact that some workplace violence is predictable in the healthcare setting, the environment of impulsiveness occasionally pervaded the workplace,particularly when considerate for patients who act unreasonably and erratically due to an emergency situation. It is highlighted in the finding of Pich, Hazelton and Kable (2013) that nurse involved in the care of the patient who has encountered gang-related violence, the situation where police and guards make the nurse unsecured and uncomfortable. The nurse narrated that they were more suspicious for serving such patients due to the prevalence of the potential threats. This shows that some of the situations in the healthcare environment are predictable, the preventive measure in the organisational sector is absent. Such finding is aligned with the research of Alyaemni and Alhudaithi (2016) and Bernaldo-De-Quirós et al. (2015). The situation makes the nurse feel that workplace violence is the part of the job as narrated by some nurse in the research of Ramacciati et al. (2018). Therefore, the review of the literature noted that not all violence in the workplace happens unintentionally, there are certain cases mostly in the accident and emergency department where violence is predictable, but there are no mitigation strategies available.

The need for support and solution

In order to solve the issue of the workplace violence experienced by the nurse in the emergency department, Lau, Magarey and Wiechula (2012) have noted that there should be empathetic communication skill among the nurses to improve the strained relationship between the nurse and patients and relatives. The finding is congruent with the research of Lau, Magarey and Wiechula (2012) in their part. Similarly, Pich, Hazelton and Kable (2013) noted that with the fast-tracking of the aggressive patient and families can be a practical strategy to prevent the occurrence of violence in the workplace. Such a solution is argued by Ramacciati et al. (2018) where they added it can allow the patient to use it as a mean of manipulating the system. They further added that to improve the working relationship of the patient and nurse and other staffs, a guideline, priority area and principle should be developed to solve the issue of violence. The solution is also supported by the Hassankhani et al. (2019); Bernaldo-De-Quirós et al. (2015) and TalasKocaöz and Akgüç (2011).

Hassankhani et al. (2019) stated that violence prevention program should be started that involves administration, staffs, workplace analysis to identify the issue, risk prevention steps and training of the healthcare staffs with continuous monitoring. Further, Bernaldo-De-Quirós et al. (2015), noted that to solve the psychological impact due to violence, psychological counselling must be made accessible to proficient staff who have been exposed to verbal violence and physical aggression.