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Workplace Violence in the Emergency Department Term Paper

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Updated: Sep 8th, 2021

Introduction

Within the clinical practice, there is an issue of nurses neglecting to report violent incidents, especially when it comes to the environment of emergency departments. It is important to educate nurses about the need not to overlook this issue and eliminate the negative emotions that persist in emergency care settings. Despite the fact that in emergency rooms, nurses are put under pressure to ensure a high quality of care, it is imperative to preserve their personal well-being to be effective in the workplace. Thus, the purpose of the current paper is to present a PICOT question on the issue of reporting violent accidents as present evidence to supplement the research on the topic.

Background

There is a steady increase in the rate of violence at emergency departments as well as other medical settings. The escalation of patients’ pain and negative emotions accompanied by the presence of “disruptive individuals turn into verbal abuse or physical assault” (Gacki-Smith et al., 2009, p. 341). This issue was chosen for exploration because of the need to preserve a positive environment in emergency care settings as they call for the provision of care to patients requiring immediate treatment. As reported by Gacki-Smith et al. (2009), emergency department staff often lack education about the procedures of reporting, hazard assessment, and de-escalation, thus subjecting themselves and patients to potential risks.

Current practices and procedures do not reach the desired standard of reporting. The lack of competence of healthcare specialists in the area contributes to the inability to stop or prevent violent incidents as well as identify situations that are not severe enough to report to law enforcement. The absence of punishment for the disruptors of peace in emergency care is likely to be remembered, contributing to the increased changes of repeated violence. Therefore, this topic is extremely important for research due to the need to change the practice and ensure that healthcare specialists understand the ramifications of not reporting violent incidents. As the target population of the further PICOT question, nurses should be the primary recipients of the interventions targeted at reducing violence in emergency settings and ensuring effective reporting procedures.

As mentioned by Stene, Larson, Levy, and Dohlman (2015) in their study, nurses’ perception of the rates of violence occurrence point to an increase in the rate rather than a decrease. The Joint Commission (2018) also investigated the problem of violence at emergency departments, finding that 75% of aggravated assaults and 93% of all assaults against healthcare workers were attributed to patients. According to OSHA (2017), around 75% of approximately 25,000 workplace violence is reported in healthcare and service settings. These statistics point to the fact that the problem is extremely important to ensure the safety of nurses in the workplace and thus should be addressed immediately.

Nursing Theorist: Jean Watson

In the exploration of the issue regarding the reporting of violent incidents in emergency settings, Jean Watson’s theory of Philosophy and Science of Caring applies the most. The theory evolved from a philosophy initially; it is focused on the existence of various relational processes in which healthcare professionals engage when interacting with their patients, their families, as well as each other (Foss-Durant, 2014). Within the established creative factors, patients are expected to express their opinions and concerns; however, violence in healthcare settings remains an issue. Watson’s theory was chosen for the current exploration because the scholar suggested that humans could not be treated as objects and should not be separated from self and others. The process of caring-to-caring is expected to build transpersonal relationships and healing potential for everyone involved in the healthcare practice. The causative factors of balance and trust are helpful in supporting the process of identifying dangerous situations in a workplace setting and manage them appropriately.

The Evidence-Based Practice Question

The PICOT question to be answered with the help of research is the following:

  • P (population): nurses and other healthcare professionals working in emergency department settings which fail to report incidents of violence;
  • I (intervention): offer opportunities for scenario-based teaching to inform nurses about the effective ways of reporting incidents of violence;
  • C (compared with): a number of incidents of violence in emergency department settings that are being currently reported;
  • O (outcome): increase the rate of violent incidents reporting;
  • T (time): within one year.

As each of the components of the relevant PICOT question has been identified, a question that will serve the future study can be developed. Thus, the developed question would be ‘in the population of nurses and other healthcare professionals working in emergency department settings that fail to report incidents of violence, can opportunities for scenario-based teaching inform nurses about the effective ways of reporting incidents of violence, increase the rate of incidents reporting compared with the current rate within a year?’

The Search for Evidence

In the search for the evidence necessary to support the research for answering the identified PICOT question, it was important to seek out information from reliable sources. To meet this objective, a search was conducted in such databases as PubMed, Cochrane Review, and CINAHL. The keywords searched in the mentioned databases were ‘emergency department violence, violence against nurses, nurses violence reporting, aggressing in emergency departments, emergency department violence prevention, nurses violence interventions.’ The exclusion criteria included research published before 2013 and non-peer-reviewed studies. Inclusion criteria for the chosen literature included the availability of full-text studies, both experimental and non-experimental designs, as well as the professional credibility of authors. It was important that the studies were written by experts in the fields of social and healthcare due to the influence of the research resulted in twenty research articles, of which five were used for the current evaluation.

It was important to include studies published between 2013 and 2018 because recent studies can provide more relevant information on the current practices of reporting cases of violence would show how severe the problem is. Potential and relevant research reports were those published in scholarly journals and had a traditional structure of research articles, including an abstract and a list of references used by their authors. It was also essential that researchers discussed their data collection and data analysis methods because of the need to determine whether the conducted procedures would yield reliable and measurable results. While not all studies included the limitations of research, it was a preferred category in the selection of studies because the acknowledgment of negative aspects of research would yield potential improvements in the future.

During the search for relevant literature, it was found that many studies on the topic of violence reporting in emergency settings were outdated. However, they included some useful information that could be potentially used in the paper. This issue points to the need to study the topic further and offer large volumes of research that would not be outdated but would provide desirable levels of expertise. As the exclusion criteria stated that no articles published before 2013 would be used, a large section of the articles resulting from the search had to be eliminated from the selection pool. Excluding non-peer-reviewed studies is explained by the fact that it is always best that the work of scholars is subjected to scrutiny from experts in the same field. Peer reviews are instrumental in checking the validity of research and ensuring that it can be published in the relevant literature. There were four studies in the selection pool that have not been peer-reviewed, which is why it was chosen to exclude them from using in the current paper.

Table of Evidence Matrix

Appraisal Tool: Non-Research EvidenceRating

Strength: Level V

Quality: Good (B)

Article Title:
Interventions to reduce the risk of violence toward emergency department staff: Current Approaches
Author(s) Ramacciati, N., Ceccagnoli, A., Addey, B., Lumini, E., & Rasero, L. Publication Date:
2016
Journal or Publication Source: Open Practice Emergency Medicine, 8,
☐ Systematic Review ☐ Clinical Practice Guidelines
  • Literature Review
☐ Individual, organizational, expert opinion, case study
Does this study apply to the population targeted for my practice question?
  • Yes
If the answer is No, STOP here (unless there are similar characteristics)
Systematic Review of Literature
  • Is the question under investigation clearly stated?
  • Yes
  • Was a rigorous peer-review process described?
  • No
  • Are search strategies presented in detail and duplicable?
  • Yes
  • Are search strategies appropriate to include all pertinent studies?
  • Yes
  • Are criteria for inclusion and exclusion of studies specified?
  • Yes
  • Are gaps in the literature identified?
  • No
  • Are study details (design, methods, and analysis) presented and comparable?
  • Yes
  • Are methodological limitations discussed?
  • No
  • Do findings answer the question posed?
  • Yes
  • Was research reviewed current (within the last 5 years or classic)?
  • Yes
  • Are recommendations made for future practice?
  • Yes
Summarize Pertinent Study Findings and Recommendations:

The study is relevant to the current research issue of violence toward ED staff because of the evaluation of existing interventions targeted at addressing the problem. However, the researchers concluded that there was weak evidence for evaluating the evaluation of interventions effectiveness. This points to the need to conduct further research on this topic, and the exploration of the PICOT question can contribute to the goal.

Will the results answer the PICO Question?
  • Yes
Evidence Rating
Strength of Evidence ☐ Level I (Strong) ☐ Level II ☐ Level III ☐ Level IV Level V
Quality of Evidence (check one) ☐ High (A)
  • Good (B)
☐ Low/Major flaw (C)
Appraisal Tool: Non-Research Evidence Rating

Strength: Level V

Quality: Good (B)

Article Title:
Managing workplace violence with evidence-based interventions
Author(s) Solorzano Martines, A. Publication Date:
2016
Journal or Publication Source: Journal of Psychosocial Nursing, 54(9)
☐ Systematic Review ☐ Clinical Practice Guidelines
  • Literature Review
☐ Individual, organizational, expert opinion, case study
Does this study apply to the population targeted for my practice question?
  • Yes
If the answer is No, STOP here (unless there are similar characteristics)
Systematic Review of Literature
  • Is the question under investigation clearly stated?
  • Yes
  • Was a rigorous peer-review process described?
  • No
  • Are search strategies presented in detail and duplicable?
  • Yes
  • Are search strategies appropriate to include all pertinent studies?
  • Yes
  • Are criteria for inclusion and exclusion of studies specified?
  • No
  • Are gaps in the literature identified?
  • No
  • Are study details (design, methods, and analysis) presented and comparable?
  • Yes
  • Are methodological limitations discussed?
  • Yes
  • Do findings answer the question posed?
  • Yes
  • Was research reviewed current (within the last 5 years or classic)?
  • Yes
  • Are recommendations made for future practice?
  • Yes
Summarize Pertinent Study Findings and Recommendations:

The findings of the study point to the need to implement evidence-based interventions for reducing the occurrence of violence while increasing the rate of reporting. The scholars underlined the importance of implementing more research studies focusing on collecting evidence for developing relevant interventions. The implications for the nursing practice are associated with the introduction of nursing programs targeted at educating them and empowering them in reporting.

Will the results answer the PICO Question?
  • Yes
Evidence Rating
Strength of Evidence ☐ Level I (Strong) ☐ Level II ☐ Level III ☐ Level IV Level V
Quality of Evidence (check one) ☐ High (A)
  • Good (B)
☐ Low/Major flaw (C)
Appraisal Tool: Research Evidence Rating

Strength: Level II

Quality: Good (B)

Article Title: At the crossroads of violence and aggression in the emergency department: Perspectives of Australian emergency nurses
Author(s) in APA format Morphet, J., Griffiths, D., Plummer, V., Innes, K., Fairhall, R., & Beattie, J. Publication Year: 2014
Journal: Australian Health Review, 38.
Setting: Emergency Department Settings in Victoria, New South Wales, and Queensland Sample Size:
Round 1: 189 participants, round 2: 160 participants, round 3: 170 participants.
Population: Nurses at Emergency Care Settings
Intervention: Three-phase Delphi technique
☐ Experimental ☐ Meta-analysis ☐ Quasi-experimental ☐ Non-experimental
  • Qualitative
☐ Meta-synthesis
Does this study provide evidence to answer the PICO question?
  • Yes
If the answer is No, STOP here (unless there are similar characteristics)
Strength of Study Design
Was the sample size adequate and appropriate?
  • Yes
Were study participants randomized?
  • No
Was there an intervention?
  • No
Was there a control group?
  • No
If there was more than one group, were groups equally treated, except for the intervention?
  • Yes
Was there an adequate description of the data collection methods?
  • Yes
Literature Review
Does the literature review identify what is known and not known about the research problem?
  • Yes
Does the literature review address gaps in knowledge? Yes
Was research reviewed current (within the last 5 years). Yes
Study Results
Were results clearly presented?
  • Yes
Was an interpretation/analysis provided?
  • Yes
Study Conclusions
Were conclusions based on clearly presented results?
  • Yes
Were study limitations identified and discussed?
  • Yes
Summarize Pertinent Study Findings and Recommendations:

The research contributes to the available body of knowledge on the topic of occupational violence. It was found that drugs, alcohol, and long waiting times contributed to the increased rates of violence in emergency department settings. However, it was indicated that there is no single solution to addressing ED violence, with effective strategies targeted at supporting healthcare professionals in terms of education and policymaking.

Will the results answer the PICO question?
  • Yes
Evidence Rating
Strength of Evidence ☐ Level I (Strong) Level II ☐ Level III ☐ Level IV ☐ Level V
Quality of Evidence (check one) ☐ High (A) Good (B) ☐ Low/Major flaw (C)
Appraisal Tool: Research Evidence Rating

Strength: Level II

Quality: Good (B)

Article Title: Nurses’ attitudes towards the reporting of violence in the emergency department.
Author(s) in APA format Hogarth, K., Beattie, J., Morphet, J. Publication Year: 2016
Journal: Australasian Emergency Nursing Journal, 19.
Setting: Emergency Department in Melbourne Sample Size: 8 in one focus group and 7 in another focus group.
Population: Nurses working at the Emergency Department
Intervention: No intervention
☐ Experimental ☐ Meta-analysis ☐ Quasi-experimental ☐ Non-experimental
  • Qualitative
☐ Meta-synthesis
Does this study provide evidence to answer the PICO question?
  • Yes
If the answer is No, STOP here (unless there are similar characteristics)
Strength of Study Design
Was the sample size adequate and appropriate?
  • Yes
Were study participants randomized?
  • No
Was there an intervention?
  • No
Was there a control group?
  • No
If there was more than one group, were groups equally treated, except for the intervention?
  • Yes
Was there an adequate description of the data collection methods?
  • Yes
Literature Review
Does the literature review identify what is known and not known about the research problem?
  • Yes
Does the literature review address gaps in knowledge? Yes
Was research reviewed current (within the last 5 years or No
classic)?
Study Results
Were results clearly presented?
  • Yes
Was an interpretation/analysis provided?
  • Yes
Study Conclusions
Were conclusions based on clearly presented results?
  • Yes
Were study limitations identified and discussed?
  • Yes
Summarize Pertinent Study Findings and Recommendations:

The study found that nurses report violence, but not regularly, and, in most cases, informally. The lack of a clear definition of violence as a concept influences the decisions of nurses not to report some incidence. There was also a high degree of selection in terms of violence reporting – nurses used their own judgment to identify which situations were worthy of their report and which ones were not. It has been recommended for nurses to engage in the development of violence reporting policies and educate themselves on the methods of violence identification.

Will the results answer the PICO question?
  • Yes
Evidence Rating
Strength of Evidence ☐ Level I (Strong) Level II ☐ Level III ☐ Level IV ☐ Level V
Quality of Evidence (check one) High (A) Good (B) ☐ Low/Major flaw (C)
Appraisal Tool: Research Evidence Rating

Strength: Level II

Quality: Good (B)

Article Title: Workplace violence in the emergency department: Giving staff the tools and support to report
Author(s) in APA format Stene, J., Larson, E., Levy, M., & Dohlman, M. Publication Year: 2015
Journal: The Permanente Journal, 19(2).
Setting: Sample Size: Initial survey – 154 participants, follow-up survey – 203
Population: Nurses working at the Emergency Department
Intervention: No intervention
☐ Experimental ☐ Meta-analysis ☐ Quasi-experimental
  • Non-experimental
☐ Qualitative ☐ Meta-synthesis
Does this study provide evidence to answer the PICO question?
  • Yes
If the answer is No, STOP here (unless there are similar characteristics)
Strength of Study Design
Was the sample size adequate and appropriate?
  • Yes
Were study participants randomized?
  • No
Was there an intervention?
  • No
Was there a control group?
  • No
If there was more than one group, were groups equally treated, except for the intervention?
  • Yes
Was there an adequate description of the data collection methods?
  • Yes
Literature Review
Does the literature review identify what is known and not known about the research problem?
  • Yes
Does the literature review address gaps in knowledge? Yes
Was research reviewed current (within the last 5 years or Yes
classic)?
Study Results
Were results clearly presented?
  • Yes
Was an interpretation/analysis provided?
  • Yes
Study Conclusions
Were conclusions based on clearly presented results?
  • Yes
Were study limitations identified and discussed?
  • Yes
Summarize Pertinent Study Findings and Recommendations:

The scholars identified that there was a need in assessing the current state, the education of patients, and existing reporting tools within EDs. As nurses reported that the rates of violence in healthcare facilities increased based on the findings of the study, it is imperative that this issue does not get overlooked. The endorsement of programs for identifying and reporting the cases of violence in EDs by healthcare leaders can increase the likelihood of reducing the occurrence of violence. In addition, there is a need to raise awareness of the problem due to the lack of its coverage in the media.

Will the results answer the PICO question?
  • Yes
Evidence Rating
Strength of Evidence ☐ Level I (Strong) Level II ☐ Level III ☐ Level IV ☐ Level V
Quality of Evidence (check one) High (A) Good (B) ☐ Low/Major flaw (C)

Discussion on Implementation of a Practice Change

As nurses represent the key personnel involved in direct interactions with patients, they represent the population within the specific setting practice in which change will take place. In order to cater to patients’ needs and expectations, the change in practice will account for their preferences and values. The intervention defined by the PICOT question will require the implementation of systematic efforts and include leadership within the clinical practice, which is why patients will not be involved in the process.

The key stakeholders involved in the current project will include nurses, nursing managers, emergency department directors, and local policymakers. The interdisciplinary collaboration between them is essential to ensuring that all professionals within the intervention are on the same page in terms of goals, objectives, and procedures. Besides, the change team made of professionals in the field of healthcare can collaborate on the basis of developing suitable assessment and reporting tools associated with the management of ED violence occurrence. Giving the staff at emergency departments the education, support, and methods of reporting violent incidence are expected to reduce the number of violent acts remaining unreported.

It is expected that such barriers as the lack of resources, understaffing, and the lack of education would limit the implementation of change (Taylor & Rew, 2010). With the lack of resources that range from financial support to available tools within emergency departments, nurses will have fewer opportunities to identify violence effectively and report it to the relevant authorities. In the case of understaffing, nurses will not have enough time to attend to all issues at an emergency department because their duties would exceed their capabilities (Cheung, Lee, & Yip, 2017). This barrier can be eliminated through effective nursing management and scheduling. In addition, the establishment of positive work conditions and fair compensation for nurses is expected to increase their satisfaction, reduce turnover and subsequently reduce understaffing (Chien & Yick, 2016). The lack of education is a barrier that is expected to reduce change readiness and can only be eliminated with the help of appropriate training and the dissemination of information.

Evaluating Organizational Change Readiness

Scenario-based training represents an approach to learning design with participants in mind and aligns with the job performance of learners. The nurses involved in the training are expected to change their approaches to managing violent situations in emergency settings and be more proactive when dealing with patients exhibiting high risks of assault. Within the anticipation of nurses becoming more aware of violence and its reporting, there may be a potential barrier of them being hesitant to act. This barrier can be associated with both personalities of nurses as well as the nature of the situation at hand.

Before implementing scenario-based training in the context of emergency departments, it is important to address nurses’ concerns both in terms of their emotional well-being and professional responsibilities. Practitioners should feel secure in their practice settings, which is why it is important for nursing managers to ensure that facilities cater to the needs of their professionals and implement appropriate measures. In addition, work environments should be enhanced with the help of relevant tools and amenities, including technologies, that will make nurses’ practice easier.

Conclusion

In summary, it is worth noting that the problem of violence in emergency departments persists to this day. The implementation of effective efforts targeted at enhancing nurses’ proactiveness is essential because the lack of consistent efforts increases the likelihood of violence occurrence. The proposed PICOT question aims to identify the effectiveness of scenario-based training in helping nurses be more effective in determining cases of violence at emergency departments and reporting them to the police. In the exploration of relevant research articles on the topic of violence in healthcare settings, it was found that nurses lacked resources, education, and training to be proactive in violence management, which reinforces the limited efforts associated with addressing stressful situations in the workplace. It is notable that further research on this topic is needed, especially through applying the perspectives of patients to understand the reasons behind violence in healthcare settings.

References

Cheung, T., Lee, P. H., & Yip, P. (2017). Workplace Violence toward Physicians and Nurses: Prevalence and correlates in Macau. International Journal of Environmental Research and Public Health, 14(8), 879.

Chien, W. T., & Yick, S. Y. (2016). An Investigation of nurses’ job satisfaction in a private hospital and its correlates. The Open Nursing Journal, 10, 99-112.

Foss-Durant A. M. (2014). Science of human caring. Global Advances in Health and Medicine, 3(Suppl 1), 9.

Gacki-Smith, J., Juarez, A. M., Boyett, L., Homeyer, C., Robinson, L., & MacLean, S. L. (2009). Violence against nurses working in US emergency departments. The Journal of Nursing Administration, 39(7), 340-349.

Hogarth, K., Beattie, J., & Morphet, J. (2016). Nurses’ attitudes towards the reporting of violence in the emergency department. Australasian Emergency Nursing Journal, 19, 75-81.

Joint Commission. (2018). Web.

Morphet, J., Griffiths, D., Plummer, V., Innes, K., Fairhall, R., & Beattie, J. (2014). At the crossroads of violence and aggression in the emergency department: Perspectives of Australian emergency nurses. Australian Health Review, 38, 194-201.

OSHA. (2017). New safety and health resources. Web.

Ramacciati, N., Ceccagnoli, A., Addey, B., Lumini, E., & Rasero, L. (2016). Interventions to reduce the risk of violence toward emergency department staff: Current approaches. Open Access Emergency Medicine, 8, 17-27.

Solorzano Martines, A. (2016). Managing workplace violence with evidence-based interventions. Journal of Psychosocial Nursing, 54(9), 31-36.

Stene, J., Larson, R., Levy., & Dohlman, M. (2015). Workplace violence in the emergency department: Giving staff the tools and support to report. The Permanente Journal, 19(2), 113-117.

Taylor, J. L., & Rew, L. (2010). A systematic review of the literature: workplace violence in the emergency department. Journal of Clinical Nursing, 20, 1072-1085.

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