NURSING AFTER NURSING AFTER SUNSETSUNSET

Violence & Aggression from a Violence & Aggression from a

Night Shift PerspectiveNight Shift Perspective

Mr. Joseph Galea RMN, RGN.Mr. Joseph Galea RMN, RGN.B.Sc.(Hons.) Mental Health Nursing, BBA(Hons.) Business B.Sc.(Hons.) Mental Health Nursing, BBA(Hons.) Business

Administration, Cert. Subst. Misuse (UK)Administration, Cert. Subst. Misuse (UK)

Departmental Nursing Manager - MCHDepartmental Nursing Manager - MCHMAPN ConferenceMAPN Conference

2nd November 20122nd November 2012

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Aims of the PresentationAims of the Presentation

1.1. Antecedents to Antecedents to Violence & Violence & AggressionAggression

2.2. Night-Shift & Night-Shift & ViolenceViolence

3.3. Effects of Violence Effects of Violence & Agression& Agression

4.4. Deescalation of a Deescalation of a CrisisCrisis

5.5. Night-Shift Night-Shift

6.6. Effect of Night- Effect of Night-ShiftShift

7.7. Sleep Disorders & Sleep Disorders & FatigueFatigue

8.8. Under-reporting Under-reporting of of

Violence & Violence & Aggression Aggression

IncidentsIncidents9.9. Recommendations Recommendations

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Introduction (i)Introduction (i)

Prevelance of violence in Prevelance of violence in healthcare healthcare (Duncan et al., 2001; Gerberich et al., (Duncan et al., 2001; Gerberich et al., 2004; Lanza, Zeiss & Reirdan, 2006a)2004; Lanza, Zeiss & Reirdan, 2006a)

Particularly on nursing staff Particularly on nursing staff (Findroff (Findroff et al., 2004; Hodgson et al., 2004; Lanza, Zeiss & Reirdan, 2006b)et al., 2004; Hodgson et al., 2004; Lanza, Zeiss & Reirdan, 2006b)

Impact on the physical & Impact on the physical & psychological health psychological health (Gerberich et al., 2004; (Gerberich et al., 2004; Lanza, 1983, 1992; Lanza et al., 2006a; Woods & Ashley, 2007)Lanza, 1983, 1992; Lanza et al., 2006a; Woods & Ashley, 2007)

Impact on the ward environment Impact on the ward environment and patients’ care and patients’ care (Flannery et al., 1995; (Flannery et al., 1995; Morrison, 1990)Morrison, 1990)

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Antecedents to Violence & Antecedents to Violence & Aggression (i)Aggression (i)

Perpetrators of physical violence = patients Perpetrators of physical violence = patients (Acik et al., 2008; Chen et al., 2008)(Acik et al., 2008; Chen et al., 2008)

Lateral violence = perpetrators of Lateral violence = perpetrators of psychological violence = staff members, co-psychological violence = staff members, co-workers & supervisors workers & supervisors (King & McInerney, 2006; Kwok (King & McInerney, 2006; Kwok et al., 2006; Johnson et al., 2007; Bigony et al., 2009)et al., 2006; Johnson et al., 2007; Bigony et al., 2009)

Reasons for aggressive & violent behaviour – Reasons for aggressive & violent behaviour – patients and nurses disagree – patients: patients and nurses disagree – patients: environmental conditions + poor environmental conditions + poor communication; nurses: patients’ mental communication; nurses: patients’ mental illness illness (Duxbury & Whittington (2005)(Duxbury & Whittington (2005)

Complex interactions of patients, staff and Complex interactions of patients, staff and culture of a specific unit culture of a specific unit (Hamrin et al., 2009)(Hamrin et al., 2009)

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Violence & Aggression

1) Patient – Patient Interaction

2) Staff-Patient Interaction

3) Patient Conflict Behaviors

4) External / Personal Issues

5) Structural Issues

6) Patient Behavioral Cues

7) Patient Emotional Cues

8) Patient Symptoms

ANTECEDENTS to Violence and Aggression

Medication Related Containment

Any other containment

Any other staff-patient interaction

Environmental Issues

Regime Issues

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Patient to Patient Patient to Patient Interaction Interaction

(Bowers et al. 2011)(Bowers et al. 2011) Physical contactPhysical contact Intrusion into Intrusion into

personal personal psychological or psychological or physical space physical space (BAAEM, (BAAEM, 2003; McPhauls & Lipscomb, 2008; 2003; McPhauls & Lipscomb, 2008; May & Grubbs, 2002; Presley & May & Grubbs, 2002; Presley & Robinson, 2002)Robinson, 2002)

CompetitionCompetition Patient engaged in an Patient engaged in an

activity activity Reaction to sexual Reaction to sexual

approachapproach

Miscummunication Miscummunication Victim doing something Victim doing something

patient wanted stopped patient wanted stopped RetaliationRetaliation Patient victim Patient victim

characteristicscharacteristics Teased / buggedTeased / bugged Provocation Provocation (Powell et al., (Powell et al.,

1994)1994)

Difference in language Difference in language and cultureand culture (Mallet & (Mallet & Dougherty, 2000)Dougherty, 2000)

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Staff-Patient Interaction Staff-Patient Interaction (Bowers et al. 2011)(Bowers et al. 2011)

Limiting patients’ Limiting patients’ freedom: freedom: (Sheridan et al., 1994; (Sheridan et al., 1994;

Lancee et al., 1995; Davis, 1991Lancee et al., 1995; Davis, 1991) ) and and the limit style of nursing the limit style of nursing staffstaff (Lancee et al., 1995; RCP, 2000)(Lancee et al., 1995; RCP, 2000)

Medication related Medication related containmentcontainment:: a) medication a) medication

administration, administration, b) staff requesting patient to b) staff requesting patient to

take medication, take medication, c) dispute over medication c) dispute over medication

(Sheridan et al., 1990; Powell et al., 1994; (Sheridan et al., 1990; Powell et al., 1994; Lancee et al., 1995; Davis, 1991)Lancee et al., 1995; Davis, 1991)

Any other containment:Any other containment: a) restraint, a) restraint, b) seclusion, b) seclusion, c) de-escalation, c) de-escalation, d) ECT, d) ECT, e) involuntary admissions e) involuntary admissions

(Fineberg et al., 1990; Powell et al., 1994)(Fineberg et al., 1990; Powell et al., 1994)

Any othe staff-patient Any othe staff-patient interactioninteraction: : a) provocation. a) provocation. b) ordering patients, b) ordering patients, c) intervening on fight or c) intervening on fight or

argument, argument, d) caring for patient, d) caring for patient, e) searching patients, e) searching patients, f) negative staff attitude f) negative staff attitude (OSHA, 2003; (OSHA, 2003;

BAAEM, 2003),BAAEM, 2003), g) physical contact, g) physical contact, h) patient engaged in an activity, h) patient engaged in an activity, i) miscommunication, i) miscommunication, j) staff too permissive, j) staff too permissive, k) staff victim characteristics, k) staff victim characteristics, l) staff errors, l) staff errors, m) violation of priority m) violation of priority (Mallet & (Mallet &

Dougerty, 2000),Dougerty, 2000), n) lack of informationn) lack of information (Mallet & (Mallet &

Dougherty, 2000),Dougherty, 2000), o) access to staffo) access to staff (McGeorge et al., 2000).(McGeorge et al., 2000).

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Patient conflict Patient conflict BehaviorsBehaviors (Bowers et al. 2011(Bowers et al. 2011)) : : a) threatening behaviour,a) threatening behaviour, b) abscondments, b) abscondments, c) substance misuse c) substance misuse (BAAEM, 2003; Johnson, (BAAEM, 2003; Johnson,

1997),1997), d) verbal agression, d) verbal agression, d) self-harm.d) self-harm.

External / PersonalExternal / Personal (Bowers et (Bowers et

al. 2011)al. 2011) : : a) money issues, a) money issues, b) visit from family member or b) visit from family member or

friendfriend (Henry & Ginn, 2002) (BAAEM, 2003),(Henry & Ginn, 2002) (BAAEM, 2003), c) receiving bad news, c) receiving bad news, d) unresolved family problem.d) unresolved family problem.

Structural & Structural & Environmental issuesEnvironmental issues (Bowers et al. 2011)(Bowers et al. 2011) : :

a) overcrowding a) overcrowding (Fineberg et al., 1990; Palmstierna (Fineberg et al., 1990; Palmstierna

et al., 1991; Lanza et al., 1994),et al., 1991; Lanza et al., 1994), b) confined environment,b) confined environment, c) noisy ward, c) noisy ward, d) patients found weapons, d) patients found weapons, e) social environment such as e) social environment such as

boredom boredom (RCP, 1998; RCP, 2000).(RCP, 1998; RCP, 2000).

Regime issues Regime issues (Bowers et al. 2011)(Bowers et al. 2011) :: a) inadequate staffing levels a) inadequate staffing levels

(McPhaul & Lipscomb,(McPhaul & Lipscomb, 2008; Gilmore-Hall, 20012008; Gilmore-Hall, 2001,, b) admitting / transferring / b) admitting / transferring /

discharged & when pts ask to discharged & when pts ask to discharge themselves against discharge themselves against medical advice medical advice (Sheridan et al., 1990;(Sheridan et al., 1990;

Powell et al., 1994; Lancee et al., 1995; Davis, 1991),Powell et al., 1994; Lancee et al., 1995; Davis, 1991), c) excessive sensory c) excessive sensory

stimulation, stimulation, d) lack of stimulation.d) lack of stimulation.

Patient Behavioral cues Patient Behavioral cues (Bowers et al. 2011)(Bowers et al. 2011) : : a) agitation, a) agitation, b) attention seeking b) attention seeking

behavior, behavior, c) increased motor activity, c) increased motor activity, d) confusion.d) confusion.

Patient emotional / mood Patient emotional / mood cues cues (Bowers et al. 2011)(Bowers et al. 2011) : : a) anger, a) anger, b) sexual frustration, b) sexual frustration, c) irritability, c) irritability, d) tobacco withdrawal, d) tobacco withdrawal, e) De) Delusionselusions (Humphreys et al., 1992)(Humphreys et al., 1992) & &

hallucinations hallucinations (Dura, 1997),(Dura, 1997), and and stress due pain or illness stress due pain or illness (ICN, (ICN, 2002; McPhauls & Lipscomb, 2008).2002; McPhauls & Lipscomb, 2008).

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Night-Shift & Violence Night-Shift & Violence (i)(i)

Violence experienced during night-shifts Violence experienced during night-shifts (Arnetz et al., 1996) (Arnetz et al., 1996) particularly before 11pm. particularly before 11pm.

Mostly occured during the afternoon – Mostly occured during the afternoon – 3pm to 11pm 3pm to 11pm (Bradley et al., 2001)(Bradley et al., 2001) – lack of – lack of structured interaction structured interaction (Drinkwater, 1982; Rice et (Drinkwater, 1982; Rice et al., 1989) al., 1989)

There is no consensus.There is no consensus. Specific times for aggression: during Specific times for aggression: during

admission – change of shifts – mealtimes admission – change of shifts – mealtimes (Pearson et al., 1986)(Pearson et al., 1986) – visiting hours – visiting hours (Way et al., 1992) (Way et al., 1992) – – administration of medicationadministration of medication (Walker & Siefert, (Walker & Siefert, 1994; Barnard et al., 1984; Depp, 1983).1994; Barnard et al., 1984; Depp, 1983).

10

0

2

4

6

8

10

12

14

6.00-7.59

8.00-11.59

12.00-11.59

14.00-17.59

18.00-19.59

20.00-21.59

22.00-5.59

Figure 1: Peak times for violent incidents

FREQUENCY

TIMEBowers et al., 2011

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Night-Shift & Violence Night-Shift & Violence (ii)(ii)

Highest numbers of incident occurred Highest numbers of incident occurred between 7am – 3.30pm (morning shifts, 49% between 7am – 3.30pm (morning shifts, 49% of the incidents); high number on afternoon of the incidents); high number on afternoon shift (36%); during night (15%) shift (36%); during night (15%) (Barlow et al., 2000)(Barlow et al., 2000)

Aggression a daytime phenomenon Aggression a daytime phenomenon (Barlow et al., (Barlow et al., 2000; Way et al., 1992; Shah et al., 1991)2000; Way et al., 1992; Shah et al., 1991)

Patients on leave – evening on return to the Patients on leave – evening on return to the ward ward (Nobel & Rodger, 1989)(Nobel & Rodger, 1989)

Preventing a patient leaving the wardPreventing a patient leaving the ward (Walker & (Walker & Siefert, 1994)Siefert, 1994)

Staff uncertain of their rolesStaff uncertain of their roles (Katz & Kirkland, 1990) (Katz & Kirkland, 1990) Substitute nursing staffSubstitute nursing staff (James et al., 1990) (James et al., 1990)

Higher staff to patient ratioHigher staff to patient ratio (Morrison, 1990; Kalgerakis (Morrison, 1990; Kalgerakis

1973; Depp, 1983) 1973; Depp, 1983) – – more than 1:1 more than 1:1 (Lanza et al., 1994)(Lanza et al., 1994)

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FIG 1: Peak shifts for violent incidents

0

2

4

6

8

10

12

14

16

Day Morning Afternoon/Evening Night

0

5

10

15

20

25

30

Bathroom Bedroom Corridor DiningRoom

Lounge Nurse office Ward door

FIG 2: Location of violent incidents

Bowers et al., 2011

%

LOCATION

FREQUENCY

SHIFT

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Victims of in-Victims of in-patient violencepatient violence

Staff – nurses Staff – nurses (90% of (90% of incidents)incidents) (Edwards et al., 1988; Noble (Edwards et al., 1988; Noble & Rodger, 1989)& Rodger, 1989)

Patients (30%) Patients (30%) were against were against patientspatients (Noble & (Noble & Rodger, 1989)Rodger, 1989)

Provoked by Provoked by patients, patients, relatives or relatives or visitorsvisitors (Powell et al., (Powell et al., 1994).1994).

Physical injuriesPhysical injuries (Chen et al., (Chen et al., 2008)2008)

Psychological traumaPsychological trauma (Chen (Chen

et al., 2008)et al., 2008) & PTSD & PTSD (Caldwell, 1992; (Caldwell, 1992; Mikkelsen & Einarsen, 2002; Hansen et al., 2006; Mikkelsen & Einarsen, 2002; Hansen et al., 2006; Bigony et al., 2009)Bigony et al., 2009)

Negative impact on the Negative impact on the mental health of nursesmental health of nurses (Pai & Lee, 2011)(Pai & Lee, 2011)

Emotional reactions Emotional reactions following violence following violence include antipathy against include antipathy against perpetrator, insult and perpetrator, insult and fearfear (Astrom et al., 2004)(Astrom et al., 2004)

Negative organisational Negative organisational outcomesoutcomes (Estryn-Behar et al., 2008; (Estryn-Behar et al., 2008; DHHS/NIOSH, 2002)DHHS/NIOSH, 2002)

Effects of Effects of Violence & Violence & AggressionAggression

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De-escalation of a CrisisDe-escalation of a Crisis

‘‘Calming the patient’ – shift from a Calming the patient’ – shift from a dominant-submissive connotation to dominant-submissive connotation to collaboration collaboration (Richmond et al., 2012).(Richmond et al., 2012).

De-escalating a patient = form of a De-escalating a patient = form of a treatment = develop internal locus treatment = develop internal locus of control of control (Richmond et al., 2012).(Richmond et al., 2012).

This involves rapid assessment & This involves rapid assessment & decision-making skillsdecision-making skills

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Skills Needed Skills Needed (Richmond et al., 2012)(Richmond et al., 2012)

Good attitudeGood attitude Observation skills – Observation skills –

verbal & non-verbal verbal & non-verbal skills skills

Risk Assessment skillsRisk Assessment skills Communication skillsCommunication skills Listening skills (active Listening skills (active

listening)listening) Active listening skillsActive listening skills Emotional intelligence Emotional intelligence

– self-monitoring– self-monitoring Positive regardPositive regard EmpathicEmpathic

Quick decision Quick decision making skillsmaking skills

Assertiveness skillsAssertiveness skills Team coordination Team coordination

skillsskills Coaching skillsCoaching skills Limit settings Limit settings Motor skillsMotor skills Offer choices and Offer choices and

optimismoptimism Restraining skillsRestraining skills Debriefing skillsDebriefing skills

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Night-Shift (i)Night-Shift (i)

Work performed after 6pm and Work performed after 6pm and before 6am the next day. before 6am the next day. (Abdalkaber & (Abdalkaber & Hayajneh, 2008)Hayajneh, 2008)

Activity at night = out of phase with Activity at night = out of phase with the circadian body temperature. = the circadian body temperature. = desynchronised state. desynchronised state. (Abdalkaber & Hayajneh, (Abdalkaber & Hayajneh, 2008)2008)

This disorientation = health & This disorientation = health & psychological effect of fatigue. psychological effect of fatigue. (Abdalkaber & Hayajneh, 2008)(Abdalkaber & Hayajneh, 2008)

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What these three sets of What these three sets of

pictures have in pictures have in common?common? (Rogers et al., 1997; (Rogers et al., 1997;

Harrington, 2001)Harrington, 2001)

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Night-Shift (ii)Night-Shift (ii) To ensure patient’s coverage nurses have to To ensure patient’s coverage nurses have to

work nights, weekends and holidays.work nights, weekends and holidays. Night nurses have higher levels of fatigue Night nurses have higher levels of fatigue

(Muecke, 2005)(Muecke, 2005) and mental tiredness and mental tiredness (Tepas et al., 2004),(Tepas et al., 2004), chronic sleep loss, sleep deprivation and on-chronic sleep loss, sleep deprivation and on-the-job sleepinessthe-job sleepiness (Hughes & Stone, 2004). (Hughes & Stone, 2004).

Rarely get the recommended 8 hrs of sleep Rarely get the recommended 8 hrs of sleep (Akerstedt, 2003).(Akerstedt, 2003).

Suffer from sleep disturbances Suffer from sleep disturbances (Barton, 1994)(Barton, 1994) – – which may have an impact on patients’ safety.which may have an impact on patients’ safety.

Less quality sleep then those working during Less quality sleep then those working during the day the day (Ruggiero, 2003; Frank & Ovens, 2002).(Ruggiero, 2003; Frank & Ovens, 2002).

Sleep deprivaton – work performance Sleep deprivaton – work performance outcomes – safety and general health of the outcomes – safety and general health of the nurse nurse (Rogers et al., 2004)(Rogers et al., 2004)

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Night-Shift (iii)Night-Shift (iii) The 2nd half of the night is where nurses The 2nd half of the night is where nurses

reported that they frequently struggle to stay reported that they frequently struggle to stay awake awake (Berger & Hobbs, 2006).(Berger & Hobbs, 2006).

Staff’s circadian rhythm – social – family life – Staff’s circadian rhythm – social – family life – general health affected general health affected (Rosa & Collingan, 1997).(Rosa & Collingan, 1997).

Nurse who work nights are more depressed Nurse who work nights are more depressed than day nursesthan day nurses (Ruggiero, 2003) (Ruggiero, 2003) / there is an / there is an association between night work and poor job association between night work and poor job satisfactionsatisfaction (Korompeli et al., 2009). (Korompeli et al., 2009).

Staff performance: Significant associations Staff performance: Significant associations between night staff and error rate between night staff and error rate (Gold et al., 1992; (Gold et al., 1992; Leff et al., 2008).Leff et al., 2008).

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Effects of Night-ShiftsEffects of Night-Shifts Two things wrong with shift-work: Two things wrong with shift-work:

Having to work when supposed to sleepHaving to work when supposed to sleep Having to sleep when supposed to be awakeHaving to sleep when supposed to be awake For some people, this can result in performance, For some people, this can result in performance,

health and social effectshealth and social effects Fatigue = less work performance + short Fatigue = less work performance + short

staffing = less the quality of patient care staffing = less the quality of patient care (Circadian Technologies, 2004)(Circadian Technologies, 2004)

Breast Cancer to be 60% higher in women Breast Cancer to be 60% higher in women night-shift workers night-shift workers (Humm, 2005; Swerdlow, 2003; Steven & (Humm, 2005; Swerdlow, 2003; Steven &

Davis, 1996) Davis, 1996) infertility, cardiovascular disease, infertility, cardiovascular disease, diabetes and gastrointestinal disordersdiabetes and gastrointestinal disorders (Humm, (Humm, 2005; Reid et al., 1997; Learhart, 2000).2005; Reid et al., 1997; Learhart, 2000).

Fatigue, irritability Fatigue, irritability (Lushington et al., 1997; Reid et al., 1997),(Lushington et al., 1997; Reid et al., 1997), reduced performance, decreased mental reduced performance, decreased mental agility agility (Alward & Monk, 2003).(Alward & Monk, 2003).

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Circadian RhythmsCircadian Rhythms Fatigue = impair memory, vigilance, reaction time, Fatigue = impair memory, vigilance, reaction time,

and communication = cyclic reductions in alertness and communication = cyclic reductions in alertness and performance and performance (Howard et al., 2002).(Howard et al., 2002).

Internal body clock – external world (zeitgebers)Internal body clock – external world (zeitgebers) High activity during the day – low activity during High activity during the day – low activity during

the nightthe night Human race is diurnalHuman race is diurnal Health problems Health problems (Crofts, 1999),(Crofts, 1999), negative effects: for the negative effects: for the

individual & the work place – decreased alertness & individual & the work place – decreased alertness & reduced job performance – affect the quality of care reduced job performance – affect the quality of care (Koller, 1996; Brown & Erkes, 1998)(Koller, 1996; Brown & Erkes, 1998)

Optimum mental performance level (2-4pm) and Optimum mental performance level (2-4pm) and maximum general awareness is between (1-7pm. maximum general awareness is between (1-7pm. Performance levels are lowest between 3.30 – Performance levels are lowest between 3.30 – 5.30am 5.30am (Coffey et al., 1998)(Coffey et al., 1998)

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Sleep Disorders (i)Sleep Disorders (i) Lack of sleep Lack of sleep (Coffey et al., 1998)(Coffey et al., 1998)

Sleep disorder – tiredness – reduced Sleep disorder – tiredness – reduced functional capacityfunctional capacity

Functional capacity may be halved after 24 Functional capacity may be halved after 24 hrs and after 48 hrs is at its lowesthrs and after 48 hrs is at its lowest

Complex decisions Complex decisions (Akerstedt, 1999)(Akerstedt, 1999) though short though short term memory recall is not effected term memory recall is not effected (Allen, 1999)(Allen, 1999)

Sleep deprivation – disrupt the circadian Sleep deprivation – disrupt the circadian rhythm – forces the body to function at rhythm – forces the body to function at night despite signals (i.e. Decreased body night despite signals (i.e. Decreased body temp. & increased melatonin (temp. & increased melatonin (Hughes & Stone, Hughes & Stone, 2004)2004)

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Sleep Disorders (ii)Sleep Disorders (ii) Sleep quantity and sleep quality affected Sleep quantity and sleep quality affected

especially with night workespecially with night work Daytime sleep not as deep or refreshingDaytime sleep not as deep or refreshing Worse when room is not quite, not dark and not Worse when room is not quite, not dark and not

comfortablecomfortable Sleep quantity: Night shift (4-6 hrs) – Day shift Sleep quantity: Night shift (4-6 hrs) – Day shift

(7.5 hrs) – Evening (8.5 hrs)(7.5 hrs) – Evening (8.5 hrs) Sleep quality: day sleep – less deep sleep (stage Sleep quality: day sleep – less deep sleep (stage

3 – 4); Rotating shift < Permanent shift3 – 4); Rotating shift < Permanent shift Sleep deprivation of 24 hours affect performance Sleep deprivation of 24 hours affect performance

level (blood alcohol levels of 0.10%) level (blood alcohol levels of 0.10%) (Dawson & Reid, (Dawson & Reid,

1997).1997). Mature vs young night shift workers Mature vs young night shift workers (Reid & (Reid & Dawson, 2001).Dawson, 2001).

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The Combination of Night The Combination of Night Shift Nursing with Shift Nursing with

Aggression & ViolenceAggression & ViolenceNight shift related Night shift related fatigue and sleep fatigue and sleep

difficultiesdifficulties (Bonnet, 2000; Harrison & (Bonnet, 2000; Harrison &

Horne, 2000)Horne, 2000)

Negative moodNegative mood Sleep loss and fatigueSleep loss and fatigue Lack of innovation and Lack of innovation and

creativitycreativity Increased distractabilityIncreased distractability Inability to deal with Inability to deal with

unexpected eventsunexpected events Inability to deviate from Inability to deviate from

previous problem-solving previous problem-solving strategiesstrategies

Unreliable temporal Unreliable temporal memorymemory

Impaired language skillsImpaired language skills Motor skill performance Motor skill performance

can be impaired can be impaired (Eastridge (Eastridge et al., 2003; Grantcharov et al., et al., 2003; Grantcharov et al., 2001)2001)

Skill error increase Skill error increase (Taffinder et al., 1998)(Taffinder et al., 1998)

Skills required when dealing with Skills required when dealing with violence & aggressionviolence & aggression

Good attitudeGood attitude Observation skills – verbal & non-verbal Observation skills – verbal & non-verbal

skills skills Risk Assessment skillsRisk Assessment skills Communication skillsCommunication skills Listening skills (active listening)Listening skills (active listening) Active listening skillsActive listening skills Emotional intelligence – self-monitoringEmotional intelligence – self-monitoring Positive regardPositive regard Quick and empathic decision making Quick and empathic decision making

skillsskills Assertiveness skillsAssertiveness skills Team coordination skillsTeam coordination skills Coaching skillsCoaching skills Limit settings Limit settings Motor skillsMotor skills Offer choices and optimismOffer choices and optimism Restraining skillsRestraining skills Debriefing skillsDebriefing skills

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Under-Reporting of Under-Reporting of ViolenceViolence

Insufficient post-incident supportInsufficient post-incident support (Pai & Lee, 2011; Kwok (Pai & Lee, 2011; Kwok et al., 2006; Kamchuchat et al., 2008)et al., 2006; Kamchuchat et al., 2008)

Stigma of victimisationStigma of victimisation (Hoff, 1992)(Hoff, 1992)

Accepted as a hazard of the professionAccepted as a hazard of the profession (Daldt, (Daldt,

1981); 1981); part of the jobpart of the job (Poster, 1996; Prins, 1999) (Poster, 1996; Prins, 1999)

Resistance from hospital administratorsResistance from hospital administrators (Lanza, (Lanza, 1991)1991)

Peer nursing pressurePeer nursing pressure (Kinross, 1992)(Kinross, 1992)

Poor or ineffective reporting mechanisms Poor or ineffective reporting mechanisms ((Lyon Lyon et al., 1981; Pearson et al., 1986; Silver & Yudofsky, 1987; Lanza, 1988; Monahan, 1989)et al., 1981; Pearson et al., 1986; Silver & Yudofsky, 1987; Lanza, 1988; Monahan, 1989)

Lack of support from organisation Lack of support from organisation (Paterson et al., (Paterson et al.,

1999)1999) but staff wasbut staff was supported by their supported by their immediate nursing colleaguesimmediate nursing colleagues (McGeorge et al., 2000)(McGeorge et al., 2000)

Lack of institutional reporting policies, Lack of institutional reporting policies, employees beliefs and concerns employees beliefs and concerns (Sofiel & Salmond, 2005); (Sofiel & Salmond, 2005); Ferns, 2005; May & Grubbs, 2002, US Dept of Labor, 2008)Ferns, 2005; May & Grubbs, 2002, US Dept of Labor, 2008)

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RecommendationsRecommendations Managment awareness – planning shift schedules – Managment awareness – planning shift schedules –

aware of biological rhythmsaware of biological rhythms..

Regular medical screening & breast screeing for night Regular medical screening & breast screeing for night female nurses over 40 years of agefemale nurses over 40 years of age

For health reasons – option to day work – option to For health reasons – option to day work – option to night worknight work

Critical incident stress debriefing or therapyCritical incident stress debriefing or therapy Training & Re-organisation of the ward routine Training & Re-organisation of the ward routine (McGeorge (McGeorge

et al., 2000)et al., 2000)

Increasing face-to-face contactIncreasing face-to-face contact Improving information sharingImproving information sharing Interaction with staff and patientsInteraction with staff and patients A significant amount of workplace aggression is A significant amount of workplace aggression is

preventable preventable (DelBel, 2003).(DelBel, 2003). Education programs for nurses Education programs for nurses on fatigue and night work on fatigue and night work (Circadian Techologies, 2004)(Circadian Techologies, 2004)

Violence prevention programs Violence prevention programs (Kindy, 2005; Anderson & Parish, 2003; (Kindy, 2005; Anderson & Parish, 2003; Gilmore-Hall, 2001; McPhaul & Lipscomb, 2008; US Dept of Labor, 2008)Gilmore-Hall, 2001; McPhaul & Lipscomb, 2008; US Dept of Labor, 2008)

27

ConclusionConclusion

Link = human interaction & violenceLink = human interaction & violence Less incidents during the night – Less incidents during the night –

atmosphere tend to be more quiteratmosphere tend to be more quiter The organisation of ward routineThe organisation of ward routine Staff-patient interaction = associated Staff-patient interaction = associated

with violencewith violence Good practioner during day not Good practioner during day not

necessarily mean good practitioner necessarily mean good practitioner during the night. during the night.

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Final thought......Final thought......

‘‘THE BEST FIGHTER IS NEVER THE BEST FIGHTER IS NEVER ANGRYANGRY’’

................ ................ Lao Tzu Lao Tzu

‘ ‘but never but never tired tired ’.......’.......

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THANK YOUTHANK YOU

30

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E., Erguder, T., & Tokdemir, M. (2008). Experience of workplace violence during medical speciality E., Erguder, T., & Tokdemir, M. (2008). Experience of workplace violence during medical speciality training in Turkey. training in Turkey. Occupational Medicine 58Occupational Medicine 58, 361-366., 361-366.

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