Workplace violence experienced by registered nurses: a concept analysis.
Abstract: Workplace violence toward nurses has increased during the last decade with serious consequences that may extend beyond individual nurses to an entire health care organisation. The variety of definitions of workplace violence experienced by registered nurses contribute to a lack of clarity about what it constitutes, which in turn jeopardizes the reporting of incidences by nurses. Drawing on the relevant literature from 1990 to 2005, a concept analysis using Walker and Avant's framework was undertaken to develop an operational definition of this phenomenon as experienced by registered nurses (excluding mental health nurses). Having a clear understanding of workplace violence assists with the creation of strategies aimed at preventing and/or resolving this problem.

Key Words: Workplace violence, registered nurses and violence, concept analysis.
Article Type: Report
Subject: Registered nurses (Crimes against)
Workplace violence (Identification and classification)
Authors: Ventura-Madangeng, Judee
Wilson, Denise
Pub Date: 11/01/2009
Publication: Name: Nursing Praxis in New Zealand Publisher: Nursing Praxis in New Zealand Audience: Academic Format: Magazine/Journal Subject: Health care industry Copyright: COPYRIGHT 2009 Nursing Praxis in New Zealand ISSN: 0112-7438
Issue: Date: Nov, 2009 Source Volume: 25 Source Issue: 3
Topic: Event Code: 980 Legal issues & crime
Product: Product Code: 8043110 Nurses, Registered NAICS Code: 621399 Offices of All Other Miscellaneous Health Practitioners
Geographic: Geographic Scope: New Zealand Geographic Code: 8NEWZ New Zealand
Accession Number: 291894328
Full Text: Introduction

Traditionally workplace violence has been defined as an incident that results in physical injury (Duncan, Hyndman, Estabrooks & Hesketh, 2001); however, this definition has changed with increasing reports of violent incidents. It is a problem that is highly relevant to nurses working in New Zealand (see for example, Bentley et al., in press; McKenna, Poole, Smith, Coverdale, & Gale, 2003). A variety of terms are evident in the literature, such as aggression, assault, 'untoward' incidents (Spokes et al., 2002), verbal threats and abuse, unwanted sexual advances (American Nurses Association (ANA), 1994), harassment, bullying, and intimidation ( Jackson, Clare, & Mannix, 2002). Absence of a universal definition for workplace violence within health care settings and ambiguity about what constitutes a violent event compromises research on the incidence and magnitude of this phenomenon. Varying definitions and unclear criteria may lead to nurses failing to identify their experience as a form of workplace violence, so preventing it being reported. The International Council of Nurses (ICN) (2007) estimated that only 20 percent of nurses experiencing some form of violence report incidents of workplace violence. Under-reporting masks a higher incidence than is indicated in the literature. We saw concept analysis as offering a strategy for reviewing the literature and comprehensively describing the nature and extent of violence that nurses experience in their practice. The study excluded those registered nurses working in mental health settings, given that the latter pose unique challenges and are already well-reported in the literature.

The study reported here aimed to develop an operational definition for workplace violence together with a set of criteria to identify the phenomenon. Naming the essential elements of workplace violence paves the way for the development of new tools as well as refinement and evaluation of existing instruments, and so facilitates future investigations. The specific objectives of this study were to:

1. Explore the defining attributes, identify the antecedents and consequences, and identify the empirical referents of workplace violence experienced by registered nurses in non-mental health settings; and

2. Formulate an operational definition for workplace violence.

Review of Literature

Workplace violence has long been recognized as a problem in psychiatric care (Arnetz, Arnetz, & Petterson, 1996; Hansen, 1996; Lanza, Kayne, Pattison, Hicks, & Islam, 1 996), aged care (Chambers, 1998; Hagan & Sayers, 2005), and emergency settings (Jackson et al., 2002; O'Connell, Young, Brooks, Hutchings, & Lofthouse, 2000). However, evidence now shows that it is equally prevalent in general ward settings, and is similar to that in psychiatric areas (Whittington, Shuttleworth, & Hill, 1996; Winstanley & Whittington, 2002).

A universal definition for workplace violence was not evident in the literature (Crilly, Chaboyer, & Creedy, 2003; Hegney, Plank, & Parker, 2003). Instead a variety of terms are used including abuse, aggression and assault (Crilly et al.). May and Grubbs (2002) argued that lack of definition led to underreporting incidents of workplace violence, so masking its extent, and creating confusion among nurses about what it constitutes. Rose (1997) stated that 63 percent of workplace violence went unreported and that 29 percent of recent physical assaults were not reported. Fear of blame and the belief that violence was just part of a nurse's job were reasons cited for not reporting violent incidents (Crilly et al.,; Hegney et al.; Lyneham, 2000; Rose).

The magnitude and severity of workplace violence has a significant impact on nursing and health care (ICN, 1999), with evidence strongly suggesting that the incidence internationally has noticeably increased (Dalphond, Gessner, Giblin, Hijazzi, & Love, 2000; Farrell, 1999; Jackson et al., 2002; Kaye, 1996). Workplace violence involves four main groups of people; patients, physicians, family and friends, and co workers (Duncan et al., 2001; Lechky & Rafuse, 1994). Inevitably because of the nature of the nurses' work, they have direct contact with potential perpetrators, making them more at risk of experiencing a violent incident.

The experience of workplace violence has physical, personal, emotional, professional, and organisational consequences that impact on individuals and organisations. We argue that a definition to aid the recognition of workplace violence, and understanding of its attributes, antecedents, and consequences will assist in optimising recognition and facilitate in the formation of strategies to address the problem.

Method

The search strategy used to select the literature for this concept analysis involved systematically searching the following databases: CINAHL, EBSCO, Medscape, Ovid, and Web of Science. A hand search of reference books was also undertaken. These sources were searched using the keywords nurses, and violence, aggression, abuse, assault, horizontal violence, bullying, harassment, and hospital, workplace, and general wards. Boolean searches included:

* nurses AND violence, nurses AND abuse, nurses AND assault, nurses AND horizontal violence, nurses AND bully*, nurses AND harassment

* violence AND hospital, violence AND work*, violence AND general OR hospital wards

The selection criteria involved literature and research published between 1990 and 2005 which explored workplace violence in general ward settings experienced by registered nurses and perpetrated by patients, medical staff or other nurses, and was relevant to formulating an operational definition for workplace violence. Literature and research related to sexual harassment and violence against nurses working in mental health settings were excluded on the basis that these had differing and unique considerations.

The results of the literature search, as described above, were used as the data source for the concept analysis. The latter entails examining the defining characteristics by breaking the concept into its simpler forms then weaving them into a coherent, well-defined, and clear concept. Walker and Avant's (1995) framework for a concept analysis was selected as it offered a strategy to investigate concepts that have been over-used and lost their meaning, of which workplace violence is an example. This exercise consists of three steps:

1. Identifying the defining attributes,

2. Determining antecedents and the consequences, and

3. Defining the observable and measurable features, known as empirical referents (Rodgers & Knafl, 1993).

The data analysed consisted of literature published from 1990 to 2005. In this study we have defined the recipient of workplace violence as the nurse.

As this study focused on published literature and did not involve human participants as such, no ethical issues or concerns were evident. Therefore, an application was submitted to the Massey University Human Ethics Committee where the study was peer reviewed and assessed as low risk.

Defining attributes are those characteristics occurring frequently in the literature. They were identified by repeated review of the literature, and arranged into clusters that aimed to aid understanding of the concept (Rodgers & Knafl, 1993; Walker & Avant, 1995). Identified attributes were recorded on a data sheet, and then classified according to common themes such as formal working relationship, power, and act or behaviour. Next the literature was reviewed again, this time aiming to identify antecedents and consequences, and so allowing causes and effects of workplace violence to be inferred (Penrod & Hupcey, 2004). The process was repeated once again to determine the empirical referents that provided the observable measures to detect the presence of workplace violence (Walker & Avant). For example, a nurse experiencing an increased heart rate when feeling bullied by a senior colleague who frequently intimidates and uses verbal put-downs (empirical referents) may lead to the nurse having a lack of appetite and insomnia (short-term consequences).

The final step involved selecting a number of reality-based cases providing a range of features that could be used to illustrate the presence or absence of defining attributes for the concept of workplace violence (Rodgers & Knafl, 1993). This included model, borderline, related, and contrary cases, and aimed to clarify the concept under study. For example, model cases are exemplars of real-life experiences that contain all the attributes resulting from the analysis of the literature for workplace violence. Additional cases considered borderline were those related or contrary to the concept of workplace violence, based on varying degrees of the critical attributes identified. These functioned to enhance the clarity of the model cases (Nies et al., 1999; Walker & Avant, 1995). However, only model cases will be reported in this article.

Findings

An overview of various components of the concept of workplace violence against registered nurses is illustrated in Figure 1, and outlined below.

Defining Attributes

The defining attributes of workplace violence explicit in the literature relate to relationships, power and behaviours (Graydon, Kasta, & Khan, 1994; McKenna et al., 2003; O' Connell et al., 2000; Randle, 2003; Robertson, 2004; Workplaces Against Violence in Employment, 2005). These were labelled as (a) formalised working relationship, (b) power and powerlessness, and (c) act or behaviour.

(a) Formalised working relationship

Formal working relationships, where individuals are mutually working to achieve a certain goal, are evident between the nurse and the client, the nurse and the client's families or visitors, the nurse and the medical practitioner, and/or the nurse and another nurse. The potential exists for workplace violence to occur in any of these relationships.

(b) Power and powerlessness

Power conflicts within the working environment are a defining characteristic. Power is used within formal relationships to achieve goals or objectives, either individually or through an interpersonal process. It can be used, misused, or abused in an attempt to disempower an individual, to elicit a favourable response from an individual, and/or to maintain power (Freshwater, 2000). Unequal power relationships such as those related to gender or position compound the situation, contributing to the occurrence of workplace violence.

(c) Act or behaviour

Act or behaviour refers to any action or behaviour by the perpetrator of the violence toward the nurse, the recipient of an act of violence. This can take the form of verbal, psychological, and/or physical abuse, and any other actions designed to intimidate.

[FIGURE 1 OMITTED]

Antecedents

As described below, the antecedents of workplace violence include (a) the presence of two or more people, at least one of whom is identified as the source or perpetrator of workplace violence (Keep 85 Gilbert, 1992; Lechky 85 Rafuse, 1994; Nabb, 2000), and the recipient (Farrell, 1999; May 85 Grubbs, 2002; Thomas, 2003). Also external stimuli (Cook, 2001; Jackson et al., 2002; Lechky 85 Rafuse; Thomas) and internal stimuli (Diaz & McMillian, 1991; Hansen, 1996; Lyneham, 2000; Murray & Snyder, 1991) must be evident.

(a) The presence of two or more individuals

Two or more persons must be present for workplace violence to exist, that is, the perpetrator and the recipient. Perpetrators of workplace violence may be a client, a family member, medical practitioner, or another nurse. While the nurse is the recipient or the victim of workplace violence in this study (as previously indicated), other nurses may also be involved as perpetrators.

(b) External stimuli

Institutional health care systems and policies

Some policies imposing limitations and rules may render clients, families and staff powerless, and so become a source of stress and anxiety (Chambers, 1998). Not uncommonly, for medical practitioners and nurses some policies and procedures in addition to busy workloads can precipitate stressful situations. Stressful situations also arise from procedures clients are subjected to that are intrusive or cause pain, or the presence of restrictive visiting policies imposed on family members, or when lifesaving interventions are cancelled. All these are factors contributing to the frustration and stress experienced by clients, families and staff. Each of these situations has the potential to precipitate workplace violence.

Workplace environment

Physical setting, access to necessary resources and the general atmosphere within the health care service may contribute to understaffing, poor communication and long delays in receiving care, giving the impression that individuals are invisible or not valued (Presley & Robinson, 2002). Workplace environments can be a source of frustration among clients, visitors, medical practitioners, and nurses especially when quality of care is seen to be compromised--the resultant frustrations increase the risk of violent incidents (Hesketh et al., 2003).

(c) Internal factors

According to Anderson (2002), any situation that increases stress may precipitate a violent incident. Internal factors are characteristics of the perpetrator or recipient that contribute to the occurrence of violence. Perpetrator characteristics include, but are not limited to, personality disorders, a past history of aggression, stress, substance and alcohol abuse, pathological conditions, insecurity, attitude problems, a sense of powerlessness, poor control, poor communication, frustration, anxiety, and fear. All of these can impair individual judgment and contribute to inappropriate actions or behaviours, increasing the likelihood of inappropriate and possibly uncharacteristic behaviours being displayed (Crilly et al., 2003).

Nurse recipients of violence may also display characteristics such as poor communication, attitude problems, and reduced performance in terms of work quality and efficiency, all of which render them more vulnerable (Levin, Hewitt, & Misner, 1998). Spokes et al. (2002) suggest that the quality of a nurse's interaction and communication during contact with a client, visitor, medical practitioner, or other nurses can be a contributing factor to the emergence of workplace violence incidents.

Consequences

Consequences are the outcomes or events that result from incidents of workplace violence (Walker & Avant, 1995). These may take the form of physical, emotional, psychological, professional, and/or organisational effects, and may be short or long-term.

Physical consequences

Physical consequences of workplace violence comprise physical injuries such as broken bones, lacerations, bruises, sprain, backaches, bites, or wounds (Gerberich et al., 2004; Levin et al., 1998; Lynch, Appelboam, & McQuillan, 2002). All potentially lead to a loss of work time, and may result in long term physical symptoms such as sleep deprivation, nausea, and headaches.

Emotional and psychological consequences

The emotional and psychological consequences of workplace violence are complex. Initially, nurses report feelings of disbelief about being involved in a violent incident, and may perceive this as a loss of power or autonomy (Chambers, 1998). Consequences include, but are not limited to, stress, emotional exhaustion, burnout, anger, fear, loss of self-esteem, loss of self confidence, anxiety, self-blame, resentment, shock, embarrassment and humiliation. Any of these may be accompanied by the use of alcohol or drugs (Gerberich et al., 2004; O'Connell et al., 2000; Winstanley & Whittington 2002).

Such consequences eventually affect the nurse's personal relationships, and are likely to be manifest in professional isolation, poor team cohesion (Duncan et al., 2001), and reduced quality of care delivered (Randle, 2003). Nurses experiencing any form of workplace violence tend to distance themselves physically and emotionally from others and their work (Winstanley & Whittington), and are often reluctant to talk about their experience for fear of blame (Levin et al., 1998).

Professional consequences

Professional consequences of workplace violence, manifested as a lack of concentration, decreased job satisfaction, burnout, increased sick leave, and uncertainty can affect a nurse's work performance (Kaye, 1996; Manderino & Berkey, 1997; Pejic, 2005; Reinick & Furino, 2005).

Safety, efficacy, and quality of care are influenced by the nurse's attitude towards the perpetrator, which may show itself as avoidance behaviour, and so disrupt teamwork (Hesketh et al., 2003; Salmond & Sofield, 2003). Levin et al. (1998) suggested that workplace violence can result in nurses becoming callous toward others.

Organisational consequences

Workplace violence is associated with increased staff turnover, problems with staff retention, and nurses transferring to another location. The physical, emotional, and professional consequences compromise quality of care, and lead to loss of productivity and increased financial costs for the health care organisation. Other possible consequences include time consuming activities involved with creating new policies and procedures, providing training and education to staff, counselling victims as well as revising schedules as a result of turnover, sick leave, and transfer of nurses to other wards (Cook, 2001; Diaz & McMillian, 1991; Duncan et al., 2001; Randle, 2003; Sommargen, 1994;).

Empirical Referents

There are observable cues that signify a potentially violent situation and provide objective measures to establish its presence. These are (a) autonomic arousal, (b) verbal aggression or abuse, (c) physical aggression or abuse, (d) intimidation, and (e) horizontal violence and bullying.

Autonomic arousal

Autonomic arousal is a sign of heightened emotions prior to a violent incident. The signs and symptoms exhibited by a potential perpetrator include, but are not limited to pacing, fast breathing, restlessness, agitation, and an increase in heart rate (Nabb, 2000; Thomas, 2003; Yassi, Tate, Cooper, Jenkins, & Trottier, 1998;). By recognising these cues strategies can be implemented to prevent an event from escalating to a violent one.

Verbal aggression or abuse

Verbal aggression or abuse may be subtle and difficult to recognise (Hesketh et al., 1998; Pejic, 2005). It is expressed through words, tone, or a manner that serves to intimidate, threaten, humiliate, or is disrespectful to the nurse (Salmond & Sofield, 2003) . Swearing, yelling, or making rude or humiliating remarks are also included in this category (May & Grubbs, 2002; Presley & Robinson, 2002; Summers, 1999).

Physical aggression or abuse

Physical aggression or abuse is the use of physical force ranging from slight physical contact to more serious bodily harm (Duxbury, 2003), and includes being pushed, grabbed, punched, scratched, kicked, bitten, pinched, pulled, hit or spat upon (May & Grubbs, 2002; Presley & Robinson, 2002); Summers, 1999).

Severe forms may involve the use of weapons or objects, strangulation, or being thrown across the room.

Intimidation

Intimidation involves behaviours or words that serve to create fear, or belittle another person. This may include throwing furniture or other items, hitting the wall or other objects in the workplace, or using threatening and disrespectful language (Graydon et al., 1994; McKenna et al., 2003; O' Connell et al., 2000).

Horizontal violence and bullying

Horizontal violence is evident when an individual or a group is systematically excluded or isolated causing the victim to feel helpless and frustrated resulting in detrimental effects (Robertson, 2004) . It is apparent where the workplace culture or norm enables dominant individuals or groups to pressure those who are vulnerable to conform to their rules. Bullying, on the other hand consists of repeated acts of horizontal violence. Horizontal violence may be obvious or hidden, trivial or repetitive, and include belittling, professional or personal humiliation, exclusion or isolation, interfering with work plans and decisions, and withholding resources (Randle, 2003; Robertson; Working Women's Centre of South Australia, 2003; Workplaces Against Violence in Employment, 2005).

Case Examples

The following two cases are examples of incidents that illustrate what is and what it is not workplace violence.

Model case

Betty went to see Emma, the charge nurse in her unit. Betty reported that the workload in the ward was becoming unacceptable and unsafe for practice. Emma became defensive saying that Betty was over-dramatic, 'slack' in her job and that her inefficiency and incompetence contributed to unsafe practice within the unit. This case is an example containing all the defining attributes of workplace violence: That is, a formal working relationship exists between Betty and Emma, with Emma in a position of power. Emma's response of verbal abuse and horizontal violence professionally degraded Betty and is again consistent with workplace violence.

Borderline case

Don was due to undergo a surgical procedure. He was observed pacing up and down the hallway looking very anxious and agitated. Robynne, a nurse, asked him if he was alright. Don did not say anything and went back to his room but exhibited signs of autonomic arousal by pacing up and down the corridor. However, while anxious he has not acted or behaved abusively towards the nurse, and therefore this cannot be considered workplace violence.

Discussion

Workplace violence against nurses is evident where power struggles within a formalised working relationship between one nurse and another nurse, a client, a family member, a visitor, or a medical practitioner exists, resulting in verbal or physical acts or behaviours that are violent, abusive, and/or intimidating. Such incidents are preceded by external systemic and environmental factors within the workplace that generate stressful circumstances and/or internal characteristics of either the perpetrator or the recipient. The consequences of workplace violence for nurses who are on the receiving end may be short- or long-term and physical, emotional, psychological or professional in nature. Organisational effects may also occur that potentially result in compromised performance and quality of care, and staffing issues.

Workplace violence against nurses has similarities with other forms of violence, such as domestic violence, dating violence, child abuse and horizontal violence. Each of these are characterised by issues of power and control whereby violent or abusive behaviour, often subtle and difficult to detect, is used by one person to assert control over another. The difference, however, is that workplace violence, as described here, generally does not include a sexual element that may be present in other forms of violence. The consequences are similar, with recipients subjected to control or coercion that leads to potential devaluing and humiliation. These may be to the point that psychological wellbeing, health and work performance are negatively affected.

Much is written on the prevalence of horizontal violence within the nursing profession (Freshwater, 2000). Dunn (2003) refers to it as professional terrorism and sabotage. Freire's (1921/1996) work on oppression can be used to explain such abusive behaviours experienced by their nursing and medical colleagues, occurring within the professional context. While Freire can be used to explain abusive behaviours by medical colleagues as an exertion of their dominance and control over nurses, it does not explain abusive behaviours by clients or family members (which is beyond the scope of this article). However, oppression by nurses toward other nurses is viewed as characteristic of oppressed group behaviour where some nurses exert dominance and control while striving to lose their oppressed status.

Social learning theory (Bandura, 1986) also provides an avenue to explain horizontal violence, where some medical staff and nurses subjected to, or who observe abusive behaviours, learn that these are effective in achieving goals and subsequently adopt them as strategies to affect desired outcomes (Manderino & Berkey, 1997). Such behaviours are reinforced and maintained when desired out comes are achieved (Bandura; Dodge, 1991; Sullivan, Meese, Swan, Mazure & Snow, 2005).

Explanations for horizontal violence, however, are limited in the context of workplace violence as they do not explain the nurse-client, nurse-family member(s), or the nurse-visitor dyads where abusive or violent acts do occur.

Workplace violence against nurses is complex, and is precipitated by various factors that lead to acts and behaviours, dependent upon the context within which it occurs. The use of violence in any form or context is both inappropriate and unacceptable; yet, systemic problems endemic in many health settings perpetuate its existence. This occurs despite employers of nurses having a legal and moral responsibility to ensure a safe working environment for all staff (Drury, 1997). In an era marked by challenging work environments, particularly with regard to inadequate staffing, and the international challenges faced by health services to recruit and retain nurses, eliminating workplace violence must be a priority.

Conclusion

Given the multiple definitions relating to workplace violence, we aimed to generate a single definition and description to aid with identifying and understanding its essential characteristics. Acts of workplace violence are manifested through verbal abuse, physical abuse, intimidation, harassment and bullying, and have detrimental physical, emotional, psychological, professional, and organisational consequences. They involve the perpetration of these behaviours by a colleague, client or client family toward a nurse whose interactions are compromised (by status or gender, for example), and precipitated by various internal and external factors. Workplace violence is a relevant issue for the New Zealand nursing workforce. Its eradication requires a committed effort among nurses, administrators, educators and leaders in the community and at national level. Similar to any other form of violence occurring in society, failure to address this serious issue has moral, ethical and legal implications for the profession, and ultimately for the delivery of quality client care.

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