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Continuing interest and awareness regarding violence towards health workers in New Zealand[[1–3]] mirrors that which is seen internationally.[[4–6]] Certain areas within healthcare are under high risk for violence and aggression (V&A), notably emergency departments/urgent care (ED), mental health care, and aged care.[[7]] Emergency care settings are sites where staff are frequently exposed to violent language and threatening behaviour. Considerable research has been published, leading to increased awareness of the significance of this issue.[[8–14]] A 2018 New Zealand study identified the impact and consequences of failure to accurately report V&A within a major hospital emergency department (ED).[[3]] It highlighted that the absence of accurate data significantly increases clinical risk by reducing recognition and response. Risks for staff exposed to workplace violence extend beyond the immediate physical and psychological impact. Exposure to occupational violence has the potential to initiate, contribute to, or exacerbate emotional exhaustion, excessive drinking, moral distress, anxiety, depression, suicidal thoughts, burnout, and post-traumatic stress disorder.[[4–6]] The consequences for health organisations include absenteeism, decreased job satisfaction leading to staff turnover, diminished productivity, and difficulties with recruitment and retention of staff. Legal significance includes the potential failure of employers to meet obligations to provide a safe workplace. This article outlines findings from a longitudinal study of V&A reporting within Christchurch Hospital ED.

Methods

This prospective, longitudinal cohort study involves repeated yearly audits of ED staff reporting V&A during the same month each year. The setting is Christchurch Hospital ED, which sees patients of all ages, and all types of presenting complaint, receiving both referrals and walk-in presentations. It is one of the busiest departments in Australasia in terms of both acuity and patient numbers, and there is no alternative ED in the city.

Repeated “May – It’s Not Ok” campaigns occurred within the ED, targeting staff awareness and willingness to report V&A, from 2014. This involved a single month (May) of data collection, with department-wide focus and reminders to report all V&A. The study uses an audit approach, focussing on the accuracy of routine reporting. Formal ethical approval was not required for this study. More detailed discussion of the studies development and methodology has previously been published.[[3]]

Data captured by the audit form asked for the professional group and gender of the staff member completing the form; the category of V&A (verbal abuse, verbal threat, physical threat, physical assault and sexual assault); date and location of incident; and, from 2016, data about the individual who committed the violence.

Data collection

Data were collected from 2014–2020 (excluding 2017). As part of the quality cycle, minor amendments were made with each iteration, in response to feedback and observations. In 2014, the initial data collection tool was introduced to provide a more efficient platform for reporting than the paper-based process then in use. This was in response to reports that the time taken to complete formal, paper-based reporting was a barrier. In 2016, an electronic system was introduced called “Safety1st”. Despite expectations that this would reduce the burden on staff, it was reported that it required a minimum of 30 minutes to complete, and also necessitated that staff found an available computer. The data collection tool used for this study was specifically designed for ease and speed of completion by busy ED staff and has been described previously.[[3]]

Data analysis

Simple descriptive statistics were applied to the numerical data, with graphical representation of key elements. The qualitative data is used as a descriptive adjunct in illustrating the categories of V&A reported.

Results

The study is now an established, ongoing quality project. Overall, similar numbers of reports have been received during each “May – It’s Not Ok” audit period, aside from 2015, when a lower response rate was received. This was believed to be due to the concurrent roll out of a V&A survey.

The relative stability in reports is interesting when considering the increase in overall patient numbers during the study period. Patient attendance numbers, admission rates, and markers for acuity (in the form of triage 1–3 statistics), together with mental health and drug/alcohol numbers, are illustrated in Table 1.

Study findings

A summary of the data collected, and the participants is outlined in Table 2. All ED staff were invited to participate in the audit, but the most consistent responses were from nursing, medical and allied health groups.

Once data collection relating to the aggressor began, it was apparent that some incidents affected multiple individuals, and some individual aggressors were responsible for multiple incidents. Many incidents affected multiple people—16 separate events in the most recent year generated more than one report, with an average of 18 such events per year over the 8 years that this data has been collected. This is based on the formal completion of forms—at times these identified that others were present or involved who did not go on to report the incident or its impact. A small number of individuals also had significant impact; as an example, three patients presented more than once during the audit period in 2020 (on 14 separate occasions), generating 22 reports.

Type of event reported

Participants were initially asked to categorise the event in terms of physical intimidation or assault, and verbal abuse or intimidation. Iterations that followed expanded the options to include categories related to sexual innuendo/threat and sexual assault, property damage and use of a weapon, and “Other”. These additions were accompanied by brief definitions, and descriptions of the type of behaviours associated with these categories.

The most consistently reported event across the study was verbal abuse, which combined with verbal threats represented between 62–76% of all reported events (mean of 69%). Instances of physical threat or assault ranged between 19–25% of all events (mean of 21%). When combined, reports of sexual innuendo/threat and assault (over the five years this was recorded, 2015–2020) ranged from 3–10% of all events (mean of 6%).

View Tables 2 & 3.

Examples of the brief summaries provided by staff reporting the incidents offer insight into the experiences and context within the ED:

“Patient loud, aggressive and agitated, threatening and standing over nurse and clerical staff. Unsafe to send him through for assessment, appears to have non-life-threatening injuries. Asked to go home and sober up but continued threatening behaviour. Police called.” (2020; RN)
“Patient brought in, intoxicated. Had already punched several paramedics and stood to urinate in back of ambulance. Vandalised R1 [room designation]. Punched ED staff. Police called and arrested patient. Patient restrained, spat in my face and tried to punch me several times. Dug fingernails into my hand. Very verbally abusive.” (2019; Doctor)
“Multiple sexual innuendos suggesting I get into bed, take my clothes off, suggestions of what he would like to do.” (2019, RN)
“Very intoxicated patient grabbing me inappropriately and fixating on me. Attempted to kiss me twice.” (2018, Hospital Aid)

Frequency of events

Despite expected variation, there were identifiable patterns relating to the time of day and day of the week when V&A was more prevalent (refer to Figure 1). Friday and Saturday had the highest average percentage of violent events reported. Friday reports ranged from 13–25%, mean of 18% (N=99; mean n=17), and Saturday ranging from 7–29% mean of 18% (N=98; mean n=16). V&A was more likely to be reported on night shifts or later in afternoon shifts (refer to Figure 2). The hours when the most reports were received was 03:00–04:00 (N=29; mean n=5) followed by 01:00–02:00 (N=22; mean n=4). The time with the lowest number of reports overall was 14:00–15:00 with only five reports across the study period.

Figure 1: Frequency of events by day of the week.

Figure 2: Frequency of events by shift.

Contributing factors

From 2016, respondents could indicate if they thought an environmental factor contributed to the event being reported. (Refer to Table 4.)

Aggressor characteristics

From 2016, information related to the perceived aggressor or instigator of the V&A event was requested. This included the role of the aggressor (refer to Table 5) and a subjective assessment by the staff member reporting about additional factors which may have contributed to the situation; for example, that the patient was intoxicated, confused or having difficulty communicating with staff (refer to Table 6). Where the perceived aggressor was a patient, demographic data was obtained from the patient’s medical record (refer to Table 7).

View Tables 4–7.

Inconsistencies in data entry in formal reporting systems

An ongoing issue with V&A data collection was highlighted in the initial iteration of the study.

A review of officially collected data by monthly quantity was undertaken to allow comparison between the May reporting and that completed at other times. This identified the discrepancy between these months, with inconsistent reporting. While “Safety1st” was formally introduced in 2016, Figure 3 indicates that the staff reporting that occurred in the May campaigns were also not entered into this system. It was not until 2018, when the May data entry role was taken over by an ED clerical officer in an effort to improve the reporting rates, that information was also entered into “Safety1st”. Even with this assistance, discrepancies between the data collected from the “May – It’s Not Okay” campaign and that retrieved from the “Safety1st” system remain—this is likely due to different ways of categorising and inputting data. Overall, this suggests remaining difficulties in gathering accurate representation of staff incidents, whether due to failing to report in the absence of additional clerical support, or difficulties in retrieving an accurate representation of events from the current system.

Figure 3: Violence and aggression reporting by month (2015–2016) from "Safety1st".

Discussion

The interest in V&A reporting is part of the wider response to violence in healthcare. This has received international attention, and increasingly is highlighted within the New Zealand health system.[[15–16]] Our study shows that repeated monitoring can reveal the presence of V&A within an ED, which raises several concerns. Comparisons with other months in the year show much lower reporting rates, suggesting that barriers to reporting remain. This is in line with international literature, which also identifies difficulties in achieving consistent reporting.[[17–19]] The use of a single, targeted audit month offers a simple way to achieve a representative sample, and a more accurate estimate of any problem. As well as identifying the issues associated with reporting, the findings acknowledge the continued presence of violent events overtime. While this article does not allow for a detailed review of the responses to V&A that have been trialled alongside the audit, these have also included: the creation of an ED specific working group; collaborative engagements within the healthcare sector; hospital and DHB policy, pathway and process development; and ED specific innovations. It is possible that in the absence of such developments, the recorded events may have been even higher, and that the apparently “constant” level, despite the increasing ED presentations, actually represents a relative improvement to the baseline. Equally, it is possible that a degree of fatigue over time has seen a reduction in the reporting rate, and that the findings are under-representative. There is clearly a cumulative presence of verbal and physical violence within the working environment. This implies for the staff and organisation that there is a need to maintain a safe workplace and a healthy work environment. These results could inform changes, such as security staffing levels at times of predicted increased V&A.

Over the time that the study has run several trends have emerged, including that nurses report the highest incidence of V&A. This is in line with international research which identifies nurses and healthcare assistants at most risk of V&A;[[20]] however, willingness to report across all disciplines needs to be considered.[[9]] Evidence shows systemic under-reporting in nursing,[[21]] although other occupational groups may also find it difficult to recognise and report V&A. Further work highlighting this is necessary, with growing recognition of violence toward medical staff and reluctance to report this being recognised.[[ 22]] Future research could explore potential correlations between staff ethnicity, age and years of ED experience, and reported incidents.

The introduction of the Shorter Stays in Emergency Departments (SSED) 6-hour target in 2009 resulted in dramatic improvements in waiting times, but since their removal in 2017, there has been significant deterioration in these times.[[23]] It might be expected that the increase in waiting times may exacerbate the V&A reported. Recognition of characteristics within the patient group show connection to alcohol and drug use as associated factors, as well as a new patient group—describing those who present with a sense of entitlement and unrealistic expectations. Analysis of free text responses led to the addition of a new category description: “manipulative behaviour”. This included the emergent theme of “it’s all about me”—an identifiable group describing those who are demanding, threatening, and wanting to progress their own care regardless of other circumstances. This was typically associated with verbal abuse and intimidation, and at times physical intimidation.

Limitations

This study has several limitations. There were changes to the staff and to the audit instrument between the data collection periods. The participants effectively self-select by choosing to report the incidents of V&A. In the absence of external observation, it is difficult to confirm accuracy of the reporting, or the number of additional but unreported incidents that may occur. Data was not collected in 2017, as an in-depth staff survey into perceptions and attitudes around V&A was run during that year, and it was felt that both processes would be too burdensome for staff. The audit has continued over a period of years, and there is likely a degree of fatigue in terms of responder participation. It is possible, but highly unlikely, that the rates of V&A occurring in ED during May are different to other months of the year. There are no major public holidays or large events happening regularly during this month, and therefore V&A in May is likely similar to most other months—or perhaps less than certain months, such as December and January where alcohol-fuelled events are more common.

Conclusions

This study highlights that V&A remains an issue within the study site. Whether this is a reduction in what might otherwise have occurred, or an ongoing trend that has not responded to interventions, is unclear. However, it also indicates that the processes of the “May – It’s Not Okay” campaign offer a simple means of gaining insight into the realities of the problem, despite consistent under-reporting. There is clear need for further research into potential responses to V&A, the impact this has on staff and bystander wellbeing, and mechanisms for supporting affected staff as well as improving reporting systems.

Summary

Abstract

Aim

To examine reported levels of violence and aggression within a tertiary level emergency department in New Zealand, and to compare incident reporting within a dedicated yearly audit period to standard organisational reporting procedures.

Method

A prospective, longitudinal cohort study involving repeated yearly audits of violence and aggression reported by emergency department staff from 2014–2020.

Results

Episodes of violence and aggression were reported at high levels during audit months compared to standard reporting, suggesting current systems do not accurately reflect the presence of violence and aggression. Levels of reported violence and aggression remained relatively static over a seven-year period, despite increasing emergency department attendances. Most events reported involved verbal abuse from patients, and occurred on weekend and night shifts. A number of potentially contributing factors were identified.

Conclusion

Persistently higher levels of violence and aggression were reported during the targeted audit months, while reporting via the organisation’s formal system during the intervening months remained at low levels. Further research is essential to monitor trends, assess the effectiveness of interventions to improve reporting, modify factors contributing to violence and aggression, and to address the impact on staff and bystanders affected in emergency departments.

Author Information

Sandra Richardson: Nurse Researcher, Emergency Department, Christchurch Hospital, Canterbury District Health Board; Senior Lecturer, School of Health Sciences, Canterbury University. Paula Grainger: Nurse Coordinator Clinical Projects, Emergency Department, Christchurch Hospital, Canterbury District Health Board. Laura Joyce: Emergency Medicine Specialist, Emergency Department, Christchurch Hospital, Canterbury District Health Board; Senior Lecturer in Emergency Medicine, Department of Surgery, University of Otago, Christchurch.

Acknowledgements

The authors wish to acknowledge the contribution and commitment of all staff working in the Christchurch Hospital Emergency Department, and to commend their continued professionalism and hard work.

Correspondence

Sandra Richardson: c/-Emergency Department, Christchurch Hospital, 4 Riccarton Avenue, Christchurch 8011. 033640270.

Correspondence Email

Sandra.richardson@cdhb.health.nz

Competing Interests

Nil.

1) Marshall, B, Craig, A, Meyer, A. Registered nurses' attitudes towards, and experiences of, aggression and violence in the acute hospital setting. Kai Tiaki Nursing Research. 2017;8:31-36.

2) Baby M, Glue P, Carlyle D. 'Violence is not part of our job': a thematic analysis of psychiatric mental health nurses' experiences of patient assaults from a New Zealand perspective. Issues Ment Health Nurs. 2014 Sep;35(9):647-55. doi: 10.3109/01612840.2014.892552. PMID: 25162186.

3) Richardson SK, Grainger PC, Ardagh MW, Morrison R. Violence and aggression in the emergency department is under-reported and under-appreciated. N Z Med J. 2018 Jun 8;131(1476):50-58. PMID: 29879726.

4) Fedele R. Ground zero: standing up against violence in our healthcare sector. Aust Nurs Midwifery J. 2016 Jul;24(1):18-23. PMID: 29236431.

5) Pekurinen V, Willman L, Virtanen M, et al. Patient Aggression and the Wellbeing of Nurses: A Cross-Sectional Survey Study in Psychiatric and Non-Psychiatric Settings. Int J Environ Res Public Health. 2017 Oct 18;14(10):1245. doi: 10.3390/ijerph14101245. PMID: 29057802.

6) Shea T, Sheehan C, Donohue R, et al. Occupational Violence and Aggression Experienced by Nursing and Caring Professionals. J Nurs Scholarsh. 2017 Mar;49(2):236-243. doi: 10.1111/jnu.12272. Epub 2016 Nov 30. PMID: 27905189.

7) Phillips JP. Workplace Violence against Health Care Workers in the United States. N Engl J Med. 2016 Apr 28;374(17):1661-9. doi: 10.1056/NEJMra1501998. PMID: 27119238.

8) Pich JV, Kable A, Hazelton M. Antecedents and precipitants of patient-related violence in the emergency department: Results from the Australian VENT Study (Violence in Emergency Nursing and Triage). Australas Emerg Nurs J. 2017 Aug;20(3):107-113. doi: 10.1016/j.aenj.2017.05.005. Epub 2017 Jul 10. PMID: 28705687.

9) Copeland D, Henry M. Workplace Violence and Perceptions of Safety Among Emergency Department Staff Members: Experiences, Expectations, Tolerance, Reporting, and Recommendations. J Trauma Nurs. 2017 Mar/Apr;24(2):65-77. doi: 10.1097/JTN.0000000000000269. PMID: 28272178.

10) Han CY, Lin CC, Barnard A, et al. Workplace violence against emergency nurses in Taiwan: A phenomenographic study. Nurs Outlook. 2017 Jul-Aug;65(4):428-435. doi: 10.1016/j.outlook.2017.04.003. Epub 2017 Apr 13. PMID: 28487095.

11) Mikkola R, Huhtala H, Paavilainen E. Work-related fear and the threats of fear among emergency department nursing staff and physicians in Finland. J Clin Nurs. 2017 Oct;26(19-20):2953-2963. doi: 10.1111/jocn.13633. Epub 2017 Feb 9. PMID: 27805740.

12) Morken T, Baste V, Johnsen GE, Rypdal K, Palmstierna T, Johansen IH. The Staff Observation Aggression Scale - Revised (SOAS-R) - adjustment and validation for emergency primary health care. BMC Health Serv Res. 2018 May 8;18(1):335. doi: 10.1186/s12913-018-3157-z. PMID: 29739398.

13) Wong AH, Combellick J, Wispelwey BA, et al. The Patient Care Paradox: An Interprofessional Qualitative Study of Agitated Patient Care in the Emergency Department. Acad Emerg Med. 2017 Feb;24(2):226-235. doi: 10.1111/acem.13117. Epub 2017 Jan 30. PMID: 27743423.

14) Tadros A, Kiefer C. Violence in the Emergency Department: A Global Problem. Psychiatr Clin North Am. 2017 Sep;40(3):575-584. doi: 10.1016/j.psc.2017.05.016. Epub 2017 Jul 4. PMID: 28800811.

15) Brown K. Middlemore Hospital seeks to stop rising violence in emergency department. 24 April 2019. Radio NZ https://www.rnz.co.nz/news/national/387654/middlemore-hospital-seeks-to-stop-rising-violence-in-emergency-department

16) Donaldson RH. Alarming levels of ED violence now normalised and shrugged off, finds NZ study. 8 June 2018. Health Central.

17) Kumari A, Kaur T, Ranjan P, et al. Workplace violence against doctors: Characteristics, risk factors, and mitigation strategies. J Postgrad Med. 2020 Jul-Sep;66(3):149-154. doi: 10.4103/jpgm.JPGM_96_20. PMID: 32675451; PMCID: PMC7542052.

18) Arnetz JE, Hamblin L, Ager J, et al. Underreporting of Workplace Violence: Comparison of Self-Report and Actual Documentation of Hospital Incidents. Workplace Health Saf. 2015 May;63(5):200-10. doi: 10.1177/2165079915574684. Epub 2015 May 22. PMID: 26002854; PMCID: PMC5006066.

19) Gillespie GL, Leming-Lee T. Chart It to Stop It: Failure Modes and Effect Analysis for the Reporting of Workplace Aggression. Nurs Clin North Am. 2019 Mar;54(1):21-32. doi: 10.1016/j.cnur.2018.10.004. Epub 2018 Dec 3. PMID: 30712543.

20) Gillespie GL, Pekar B, Byczkowski TL, Fisher BS. Worker, workplace, and community/environmental risk factors for workplace violence in emergency departments. Arch Environ Occup Health. 2017 Mar 4;72(2):79-86. doi: 10.1080/19338244.2016.1160861. Epub 2016 Mar 15. PMID: 26980080.

21) Hogarth KM, Beattie J, Morphet J. Nurses' attitudes towards the reporting of violence in the emergency department. Australas Emerg Nurs J. 2016 May;19(2):75-81. doi: 10.1016/j.aenj.2015.03.006. Epub 2015 May 23. PMID: 26012889.

22) Berlanda S, Pedrazza M, Fraizzoli M, de Cordova F. Addressing Risks of Violence against Healthcare Staff in Emergency Departments: The Effects of Job Satisfaction and Attachment Style. Biomed Res Int. 2019 May 28;2019:5430870. doi: 10.1155/2019/5430870. PMID: 31275976; PMCID: PMC6558649.

23) Jones P, Le Fevre J, Harper A, Wells S, Stewart J, Curtis E, Reid P, Ameratunga S. Effect of the Shorter Stays in Emergency Departments time target policy on key indicators of quality of care. 2017 May 12; 130(1455): 35-44.

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Continuing interest and awareness regarding violence towards health workers in New Zealand[[1–3]] mirrors that which is seen internationally.[[4–6]] Certain areas within healthcare are under high risk for violence and aggression (V&A), notably emergency departments/urgent care (ED), mental health care, and aged care.[[7]] Emergency care settings are sites where staff are frequently exposed to violent language and threatening behaviour. Considerable research has been published, leading to increased awareness of the significance of this issue.[[8–14]] A 2018 New Zealand study identified the impact and consequences of failure to accurately report V&A within a major hospital emergency department (ED).[[3]] It highlighted that the absence of accurate data significantly increases clinical risk by reducing recognition and response. Risks for staff exposed to workplace violence extend beyond the immediate physical and psychological impact. Exposure to occupational violence has the potential to initiate, contribute to, or exacerbate emotional exhaustion, excessive drinking, moral distress, anxiety, depression, suicidal thoughts, burnout, and post-traumatic stress disorder.[[4–6]] The consequences for health organisations include absenteeism, decreased job satisfaction leading to staff turnover, diminished productivity, and difficulties with recruitment and retention of staff. Legal significance includes the potential failure of employers to meet obligations to provide a safe workplace. This article outlines findings from a longitudinal study of V&A reporting within Christchurch Hospital ED.

Methods

This prospective, longitudinal cohort study involves repeated yearly audits of ED staff reporting V&A during the same month each year. The setting is Christchurch Hospital ED, which sees patients of all ages, and all types of presenting complaint, receiving both referrals and walk-in presentations. It is one of the busiest departments in Australasia in terms of both acuity and patient numbers, and there is no alternative ED in the city.

Repeated “May – It’s Not Ok” campaigns occurred within the ED, targeting staff awareness and willingness to report V&A, from 2014. This involved a single month (May) of data collection, with department-wide focus and reminders to report all V&A. The study uses an audit approach, focussing on the accuracy of routine reporting. Formal ethical approval was not required for this study. More detailed discussion of the studies development and methodology has previously been published.[[3]]

Data captured by the audit form asked for the professional group and gender of the staff member completing the form; the category of V&A (verbal abuse, verbal threat, physical threat, physical assault and sexual assault); date and location of incident; and, from 2016, data about the individual who committed the violence.

Data collection

Data were collected from 2014–2020 (excluding 2017). As part of the quality cycle, minor amendments were made with each iteration, in response to feedback and observations. In 2014, the initial data collection tool was introduced to provide a more efficient platform for reporting than the paper-based process then in use. This was in response to reports that the time taken to complete formal, paper-based reporting was a barrier. In 2016, an electronic system was introduced called “Safety1st”. Despite expectations that this would reduce the burden on staff, it was reported that it required a minimum of 30 minutes to complete, and also necessitated that staff found an available computer. The data collection tool used for this study was specifically designed for ease and speed of completion by busy ED staff and has been described previously.[[3]]

Data analysis

Simple descriptive statistics were applied to the numerical data, with graphical representation of key elements. The qualitative data is used as a descriptive adjunct in illustrating the categories of V&A reported.

Results

The study is now an established, ongoing quality project. Overall, similar numbers of reports have been received during each “May – It’s Not Ok” audit period, aside from 2015, when a lower response rate was received. This was believed to be due to the concurrent roll out of a V&A survey.

The relative stability in reports is interesting when considering the increase in overall patient numbers during the study period. Patient attendance numbers, admission rates, and markers for acuity (in the form of triage 1–3 statistics), together with mental health and drug/alcohol numbers, are illustrated in Table 1.

Study findings

A summary of the data collected, and the participants is outlined in Table 2. All ED staff were invited to participate in the audit, but the most consistent responses were from nursing, medical and allied health groups.

Once data collection relating to the aggressor began, it was apparent that some incidents affected multiple individuals, and some individual aggressors were responsible for multiple incidents. Many incidents affected multiple people—16 separate events in the most recent year generated more than one report, with an average of 18 such events per year over the 8 years that this data has been collected. This is based on the formal completion of forms—at times these identified that others were present or involved who did not go on to report the incident or its impact. A small number of individuals also had significant impact; as an example, three patients presented more than once during the audit period in 2020 (on 14 separate occasions), generating 22 reports.

Type of event reported

Participants were initially asked to categorise the event in terms of physical intimidation or assault, and verbal abuse or intimidation. Iterations that followed expanded the options to include categories related to sexual innuendo/threat and sexual assault, property damage and use of a weapon, and “Other”. These additions were accompanied by brief definitions, and descriptions of the type of behaviours associated with these categories.

The most consistently reported event across the study was verbal abuse, which combined with verbal threats represented between 62–76% of all reported events (mean of 69%). Instances of physical threat or assault ranged between 19–25% of all events (mean of 21%). When combined, reports of sexual innuendo/threat and assault (over the five years this was recorded, 2015–2020) ranged from 3–10% of all events (mean of 6%).

View Tables 2 & 3.

Examples of the brief summaries provided by staff reporting the incidents offer insight into the experiences and context within the ED:

“Patient loud, aggressive and agitated, threatening and standing over nurse and clerical staff. Unsafe to send him through for assessment, appears to have non-life-threatening injuries. Asked to go home and sober up but continued threatening behaviour. Police called.” (2020; RN)
“Patient brought in, intoxicated. Had already punched several paramedics and stood to urinate in back of ambulance. Vandalised R1 [room designation]. Punched ED staff. Police called and arrested patient. Patient restrained, spat in my face and tried to punch me several times. Dug fingernails into my hand. Very verbally abusive.” (2019; Doctor)
“Multiple sexual innuendos suggesting I get into bed, take my clothes off, suggestions of what he would like to do.” (2019, RN)
“Very intoxicated patient grabbing me inappropriately and fixating on me. Attempted to kiss me twice.” (2018, Hospital Aid)

Frequency of events

Despite expected variation, there were identifiable patterns relating to the time of day and day of the week when V&A was more prevalent (refer to Figure 1). Friday and Saturday had the highest average percentage of violent events reported. Friday reports ranged from 13–25%, mean of 18% (N=99; mean n=17), and Saturday ranging from 7–29% mean of 18% (N=98; mean n=16). V&A was more likely to be reported on night shifts or later in afternoon shifts (refer to Figure 2). The hours when the most reports were received was 03:00–04:00 (N=29; mean n=5) followed by 01:00–02:00 (N=22; mean n=4). The time with the lowest number of reports overall was 14:00–15:00 with only five reports across the study period.

Figure 1: Frequency of events by day of the week.

Figure 2: Frequency of events by shift.

Contributing factors

From 2016, respondents could indicate if they thought an environmental factor contributed to the event being reported. (Refer to Table 4.)

Aggressor characteristics

From 2016, information related to the perceived aggressor or instigator of the V&A event was requested. This included the role of the aggressor (refer to Table 5) and a subjective assessment by the staff member reporting about additional factors which may have contributed to the situation; for example, that the patient was intoxicated, confused or having difficulty communicating with staff (refer to Table 6). Where the perceived aggressor was a patient, demographic data was obtained from the patient’s medical record (refer to Table 7).

View Tables 4–7.

Inconsistencies in data entry in formal reporting systems

An ongoing issue with V&A data collection was highlighted in the initial iteration of the study.

A review of officially collected data by monthly quantity was undertaken to allow comparison between the May reporting and that completed at other times. This identified the discrepancy between these months, with inconsistent reporting. While “Safety1st” was formally introduced in 2016, Figure 3 indicates that the staff reporting that occurred in the May campaigns were also not entered into this system. It was not until 2018, when the May data entry role was taken over by an ED clerical officer in an effort to improve the reporting rates, that information was also entered into “Safety1st”. Even with this assistance, discrepancies between the data collected from the “May – It’s Not Okay” campaign and that retrieved from the “Safety1st” system remain—this is likely due to different ways of categorising and inputting data. Overall, this suggests remaining difficulties in gathering accurate representation of staff incidents, whether due to failing to report in the absence of additional clerical support, or difficulties in retrieving an accurate representation of events from the current system.

Figure 3: Violence and aggression reporting by month (2015–2016) from "Safety1st".

Discussion

The interest in V&A reporting is part of the wider response to violence in healthcare. This has received international attention, and increasingly is highlighted within the New Zealand health system.[[15–16]] Our study shows that repeated monitoring can reveal the presence of V&A within an ED, which raises several concerns. Comparisons with other months in the year show much lower reporting rates, suggesting that barriers to reporting remain. This is in line with international literature, which also identifies difficulties in achieving consistent reporting.[[17–19]] The use of a single, targeted audit month offers a simple way to achieve a representative sample, and a more accurate estimate of any problem. As well as identifying the issues associated with reporting, the findings acknowledge the continued presence of violent events overtime. While this article does not allow for a detailed review of the responses to V&A that have been trialled alongside the audit, these have also included: the creation of an ED specific working group; collaborative engagements within the healthcare sector; hospital and DHB policy, pathway and process development; and ED specific innovations. It is possible that in the absence of such developments, the recorded events may have been even higher, and that the apparently “constant” level, despite the increasing ED presentations, actually represents a relative improvement to the baseline. Equally, it is possible that a degree of fatigue over time has seen a reduction in the reporting rate, and that the findings are under-representative. There is clearly a cumulative presence of verbal and physical violence within the working environment. This implies for the staff and organisation that there is a need to maintain a safe workplace and a healthy work environment. These results could inform changes, such as security staffing levels at times of predicted increased V&A.

Over the time that the study has run several trends have emerged, including that nurses report the highest incidence of V&A. This is in line with international research which identifies nurses and healthcare assistants at most risk of V&A;[[20]] however, willingness to report across all disciplines needs to be considered.[[9]] Evidence shows systemic under-reporting in nursing,[[21]] although other occupational groups may also find it difficult to recognise and report V&A. Further work highlighting this is necessary, with growing recognition of violence toward medical staff and reluctance to report this being recognised.[[ 22]] Future research could explore potential correlations between staff ethnicity, age and years of ED experience, and reported incidents.

The introduction of the Shorter Stays in Emergency Departments (SSED) 6-hour target in 2009 resulted in dramatic improvements in waiting times, but since their removal in 2017, there has been significant deterioration in these times.[[23]] It might be expected that the increase in waiting times may exacerbate the V&A reported. Recognition of characteristics within the patient group show connection to alcohol and drug use as associated factors, as well as a new patient group—describing those who present with a sense of entitlement and unrealistic expectations. Analysis of free text responses led to the addition of a new category description: “manipulative behaviour”. This included the emergent theme of “it’s all about me”—an identifiable group describing those who are demanding, threatening, and wanting to progress their own care regardless of other circumstances. This was typically associated with verbal abuse and intimidation, and at times physical intimidation.

Limitations

This study has several limitations. There were changes to the staff and to the audit instrument between the data collection periods. The participants effectively self-select by choosing to report the incidents of V&A. In the absence of external observation, it is difficult to confirm accuracy of the reporting, or the number of additional but unreported incidents that may occur. Data was not collected in 2017, as an in-depth staff survey into perceptions and attitudes around V&A was run during that year, and it was felt that both processes would be too burdensome for staff. The audit has continued over a period of years, and there is likely a degree of fatigue in terms of responder participation. It is possible, but highly unlikely, that the rates of V&A occurring in ED during May are different to other months of the year. There are no major public holidays or large events happening regularly during this month, and therefore V&A in May is likely similar to most other months—or perhaps less than certain months, such as December and January where alcohol-fuelled events are more common.

Conclusions

This study highlights that V&A remains an issue within the study site. Whether this is a reduction in what might otherwise have occurred, or an ongoing trend that has not responded to interventions, is unclear. However, it also indicates that the processes of the “May – It’s Not Okay” campaign offer a simple means of gaining insight into the realities of the problem, despite consistent under-reporting. There is clear need for further research into potential responses to V&A, the impact this has on staff and bystander wellbeing, and mechanisms for supporting affected staff as well as improving reporting systems.

Summary

Abstract

Aim

To examine reported levels of violence and aggression within a tertiary level emergency department in New Zealand, and to compare incident reporting within a dedicated yearly audit period to standard organisational reporting procedures.

Method

A prospective, longitudinal cohort study involving repeated yearly audits of violence and aggression reported by emergency department staff from 2014–2020.

Results

Episodes of violence and aggression were reported at high levels during audit months compared to standard reporting, suggesting current systems do not accurately reflect the presence of violence and aggression. Levels of reported violence and aggression remained relatively static over a seven-year period, despite increasing emergency department attendances. Most events reported involved verbal abuse from patients, and occurred on weekend and night shifts. A number of potentially contributing factors were identified.

Conclusion

Persistently higher levels of violence and aggression were reported during the targeted audit months, while reporting via the organisation’s formal system during the intervening months remained at low levels. Further research is essential to monitor trends, assess the effectiveness of interventions to improve reporting, modify factors contributing to violence and aggression, and to address the impact on staff and bystanders affected in emergency departments.

Author Information

Sandra Richardson: Nurse Researcher, Emergency Department, Christchurch Hospital, Canterbury District Health Board; Senior Lecturer, School of Health Sciences, Canterbury University. Paula Grainger: Nurse Coordinator Clinical Projects, Emergency Department, Christchurch Hospital, Canterbury District Health Board. Laura Joyce: Emergency Medicine Specialist, Emergency Department, Christchurch Hospital, Canterbury District Health Board; Senior Lecturer in Emergency Medicine, Department of Surgery, University of Otago, Christchurch.

Acknowledgements

The authors wish to acknowledge the contribution and commitment of all staff working in the Christchurch Hospital Emergency Department, and to commend their continued professionalism and hard work.

Correspondence

Sandra Richardson: c/-Emergency Department, Christchurch Hospital, 4 Riccarton Avenue, Christchurch 8011. 033640270.

Correspondence Email

Sandra.richardson@cdhb.health.nz

Competing Interests

Nil.

1) Marshall, B, Craig, A, Meyer, A. Registered nurses' attitudes towards, and experiences of, aggression and violence in the acute hospital setting. Kai Tiaki Nursing Research. 2017;8:31-36.

2) Baby M, Glue P, Carlyle D. 'Violence is not part of our job': a thematic analysis of psychiatric mental health nurses' experiences of patient assaults from a New Zealand perspective. Issues Ment Health Nurs. 2014 Sep;35(9):647-55. doi: 10.3109/01612840.2014.892552. PMID: 25162186.

3) Richardson SK, Grainger PC, Ardagh MW, Morrison R. Violence and aggression in the emergency department is under-reported and under-appreciated. N Z Med J. 2018 Jun 8;131(1476):50-58. PMID: 29879726.

4) Fedele R. Ground zero: standing up against violence in our healthcare sector. Aust Nurs Midwifery J. 2016 Jul;24(1):18-23. PMID: 29236431.

5) Pekurinen V, Willman L, Virtanen M, et al. Patient Aggression and the Wellbeing of Nurses: A Cross-Sectional Survey Study in Psychiatric and Non-Psychiatric Settings. Int J Environ Res Public Health. 2017 Oct 18;14(10):1245. doi: 10.3390/ijerph14101245. PMID: 29057802.

6) Shea T, Sheehan C, Donohue R, et al. Occupational Violence and Aggression Experienced by Nursing and Caring Professionals. J Nurs Scholarsh. 2017 Mar;49(2):236-243. doi: 10.1111/jnu.12272. Epub 2016 Nov 30. PMID: 27905189.

7) Phillips JP. Workplace Violence against Health Care Workers in the United States. N Engl J Med. 2016 Apr 28;374(17):1661-9. doi: 10.1056/NEJMra1501998. PMID: 27119238.

8) Pich JV, Kable A, Hazelton M. Antecedents and precipitants of patient-related violence in the emergency department: Results from the Australian VENT Study (Violence in Emergency Nursing and Triage). Australas Emerg Nurs J. 2017 Aug;20(3):107-113. doi: 10.1016/j.aenj.2017.05.005. Epub 2017 Jul 10. PMID: 28705687.

9) Copeland D, Henry M. Workplace Violence and Perceptions of Safety Among Emergency Department Staff Members: Experiences, Expectations, Tolerance, Reporting, and Recommendations. J Trauma Nurs. 2017 Mar/Apr;24(2):65-77. doi: 10.1097/JTN.0000000000000269. PMID: 28272178.

10) Han CY, Lin CC, Barnard A, et al. Workplace violence against emergency nurses in Taiwan: A phenomenographic study. Nurs Outlook. 2017 Jul-Aug;65(4):428-435. doi: 10.1016/j.outlook.2017.04.003. Epub 2017 Apr 13. PMID: 28487095.

11) Mikkola R, Huhtala H, Paavilainen E. Work-related fear and the threats of fear among emergency department nursing staff and physicians in Finland. J Clin Nurs. 2017 Oct;26(19-20):2953-2963. doi: 10.1111/jocn.13633. Epub 2017 Feb 9. PMID: 27805740.

12) Morken T, Baste V, Johnsen GE, Rypdal K, Palmstierna T, Johansen IH. The Staff Observation Aggression Scale - Revised (SOAS-R) - adjustment and validation for emergency primary health care. BMC Health Serv Res. 2018 May 8;18(1):335. doi: 10.1186/s12913-018-3157-z. PMID: 29739398.

13) Wong AH, Combellick J, Wispelwey BA, et al. The Patient Care Paradox: An Interprofessional Qualitative Study of Agitated Patient Care in the Emergency Department. Acad Emerg Med. 2017 Feb;24(2):226-235. doi: 10.1111/acem.13117. Epub 2017 Jan 30. PMID: 27743423.

14) Tadros A, Kiefer C. Violence in the Emergency Department: A Global Problem. Psychiatr Clin North Am. 2017 Sep;40(3):575-584. doi: 10.1016/j.psc.2017.05.016. Epub 2017 Jul 4. PMID: 28800811.

15) Brown K. Middlemore Hospital seeks to stop rising violence in emergency department. 24 April 2019. Radio NZ https://www.rnz.co.nz/news/national/387654/middlemore-hospital-seeks-to-stop-rising-violence-in-emergency-department

16) Donaldson RH. Alarming levels of ED violence now normalised and shrugged off, finds NZ study. 8 June 2018. Health Central.

17) Kumari A, Kaur T, Ranjan P, et al. Workplace violence against doctors: Characteristics, risk factors, and mitigation strategies. J Postgrad Med. 2020 Jul-Sep;66(3):149-154. doi: 10.4103/jpgm.JPGM_96_20. PMID: 32675451; PMCID: PMC7542052.

18) Arnetz JE, Hamblin L, Ager J, et al. Underreporting of Workplace Violence: Comparison of Self-Report and Actual Documentation of Hospital Incidents. Workplace Health Saf. 2015 May;63(5):200-10. doi: 10.1177/2165079915574684. Epub 2015 May 22. PMID: 26002854; PMCID: PMC5006066.

19) Gillespie GL, Leming-Lee T. Chart It to Stop It: Failure Modes and Effect Analysis for the Reporting of Workplace Aggression. Nurs Clin North Am. 2019 Mar;54(1):21-32. doi: 10.1016/j.cnur.2018.10.004. Epub 2018 Dec 3. PMID: 30712543.

20) Gillespie GL, Pekar B, Byczkowski TL, Fisher BS. Worker, workplace, and community/environmental risk factors for workplace violence in emergency departments. Arch Environ Occup Health. 2017 Mar 4;72(2):79-86. doi: 10.1080/19338244.2016.1160861. Epub 2016 Mar 15. PMID: 26980080.

21) Hogarth KM, Beattie J, Morphet J. Nurses' attitudes towards the reporting of violence in the emergency department. Australas Emerg Nurs J. 2016 May;19(2):75-81. doi: 10.1016/j.aenj.2015.03.006. Epub 2015 May 23. PMID: 26012889.

22) Berlanda S, Pedrazza M, Fraizzoli M, de Cordova F. Addressing Risks of Violence against Healthcare Staff in Emergency Departments: The Effects of Job Satisfaction and Attachment Style. Biomed Res Int. 2019 May 28;2019:5430870. doi: 10.1155/2019/5430870. PMID: 31275976; PMCID: PMC6558649.

23) Jones P, Le Fevre J, Harper A, Wells S, Stewart J, Curtis E, Reid P, Ameratunga S. Effect of the Shorter Stays in Emergency Departments time target policy on key indicators of quality of care. 2017 May 12; 130(1455): 35-44.

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Continuing interest and awareness regarding violence towards health workers in New Zealand[[1–3]] mirrors that which is seen internationally.[[4–6]] Certain areas within healthcare are under high risk for violence and aggression (V&A), notably emergency departments/urgent care (ED), mental health care, and aged care.[[7]] Emergency care settings are sites where staff are frequently exposed to violent language and threatening behaviour. Considerable research has been published, leading to increased awareness of the significance of this issue.[[8–14]] A 2018 New Zealand study identified the impact and consequences of failure to accurately report V&A within a major hospital emergency department (ED).[[3]] It highlighted that the absence of accurate data significantly increases clinical risk by reducing recognition and response. Risks for staff exposed to workplace violence extend beyond the immediate physical and psychological impact. Exposure to occupational violence has the potential to initiate, contribute to, or exacerbate emotional exhaustion, excessive drinking, moral distress, anxiety, depression, suicidal thoughts, burnout, and post-traumatic stress disorder.[[4–6]] The consequences for health organisations include absenteeism, decreased job satisfaction leading to staff turnover, diminished productivity, and difficulties with recruitment and retention of staff. Legal significance includes the potential failure of employers to meet obligations to provide a safe workplace. This article outlines findings from a longitudinal study of V&A reporting within Christchurch Hospital ED.

Methods

This prospective, longitudinal cohort study involves repeated yearly audits of ED staff reporting V&A during the same month each year. The setting is Christchurch Hospital ED, which sees patients of all ages, and all types of presenting complaint, receiving both referrals and walk-in presentations. It is one of the busiest departments in Australasia in terms of both acuity and patient numbers, and there is no alternative ED in the city.

Repeated “May – It’s Not Ok” campaigns occurred within the ED, targeting staff awareness and willingness to report V&A, from 2014. This involved a single month (May) of data collection, with department-wide focus and reminders to report all V&A. The study uses an audit approach, focussing on the accuracy of routine reporting. Formal ethical approval was not required for this study. More detailed discussion of the studies development and methodology has previously been published.[[3]]

Data captured by the audit form asked for the professional group and gender of the staff member completing the form; the category of V&A (verbal abuse, verbal threat, physical threat, physical assault and sexual assault); date and location of incident; and, from 2016, data about the individual who committed the violence.

Data collection

Data were collected from 2014–2020 (excluding 2017). As part of the quality cycle, minor amendments were made with each iteration, in response to feedback and observations. In 2014, the initial data collection tool was introduced to provide a more efficient platform for reporting than the paper-based process then in use. This was in response to reports that the time taken to complete formal, paper-based reporting was a barrier. In 2016, an electronic system was introduced called “Safety1st”. Despite expectations that this would reduce the burden on staff, it was reported that it required a minimum of 30 minutes to complete, and also necessitated that staff found an available computer. The data collection tool used for this study was specifically designed for ease and speed of completion by busy ED staff and has been described previously.[[3]]

Data analysis

Simple descriptive statistics were applied to the numerical data, with graphical representation of key elements. The qualitative data is used as a descriptive adjunct in illustrating the categories of V&A reported.

Results

The study is now an established, ongoing quality project. Overall, similar numbers of reports have been received during each “May – It’s Not Ok” audit period, aside from 2015, when a lower response rate was received. This was believed to be due to the concurrent roll out of a V&A survey.

The relative stability in reports is interesting when considering the increase in overall patient numbers during the study period. Patient attendance numbers, admission rates, and markers for acuity (in the form of triage 1–3 statistics), together with mental health and drug/alcohol numbers, are illustrated in Table 1.

Study findings

A summary of the data collected, and the participants is outlined in Table 2. All ED staff were invited to participate in the audit, but the most consistent responses were from nursing, medical and allied health groups.

Once data collection relating to the aggressor began, it was apparent that some incidents affected multiple individuals, and some individual aggressors were responsible for multiple incidents. Many incidents affected multiple people—16 separate events in the most recent year generated more than one report, with an average of 18 such events per year over the 8 years that this data has been collected. This is based on the formal completion of forms—at times these identified that others were present or involved who did not go on to report the incident or its impact. A small number of individuals also had significant impact; as an example, three patients presented more than once during the audit period in 2020 (on 14 separate occasions), generating 22 reports.

Type of event reported

Participants were initially asked to categorise the event in terms of physical intimidation or assault, and verbal abuse or intimidation. Iterations that followed expanded the options to include categories related to sexual innuendo/threat and sexual assault, property damage and use of a weapon, and “Other”. These additions were accompanied by brief definitions, and descriptions of the type of behaviours associated with these categories.

The most consistently reported event across the study was verbal abuse, which combined with verbal threats represented between 62–76% of all reported events (mean of 69%). Instances of physical threat or assault ranged between 19–25% of all events (mean of 21%). When combined, reports of sexual innuendo/threat and assault (over the five years this was recorded, 2015–2020) ranged from 3–10% of all events (mean of 6%).

View Tables 2 & 3.

Examples of the brief summaries provided by staff reporting the incidents offer insight into the experiences and context within the ED:

“Patient loud, aggressive and agitated, threatening and standing over nurse and clerical staff. Unsafe to send him through for assessment, appears to have non-life-threatening injuries. Asked to go home and sober up but continued threatening behaviour. Police called.” (2020; RN)
“Patient brought in, intoxicated. Had already punched several paramedics and stood to urinate in back of ambulance. Vandalised R1 [room designation]. Punched ED staff. Police called and arrested patient. Patient restrained, spat in my face and tried to punch me several times. Dug fingernails into my hand. Very verbally abusive.” (2019; Doctor)
“Multiple sexual innuendos suggesting I get into bed, take my clothes off, suggestions of what he would like to do.” (2019, RN)
“Very intoxicated patient grabbing me inappropriately and fixating on me. Attempted to kiss me twice.” (2018, Hospital Aid)

Frequency of events

Despite expected variation, there were identifiable patterns relating to the time of day and day of the week when V&A was more prevalent (refer to Figure 1). Friday and Saturday had the highest average percentage of violent events reported. Friday reports ranged from 13–25%, mean of 18% (N=99; mean n=17), and Saturday ranging from 7–29% mean of 18% (N=98; mean n=16). V&A was more likely to be reported on night shifts or later in afternoon shifts (refer to Figure 2). The hours when the most reports were received was 03:00–04:00 (N=29; mean n=5) followed by 01:00–02:00 (N=22; mean n=4). The time with the lowest number of reports overall was 14:00–15:00 with only five reports across the study period.

Figure 1: Frequency of events by day of the week.

Figure 2: Frequency of events by shift.

Contributing factors

From 2016, respondents could indicate if they thought an environmental factor contributed to the event being reported. (Refer to Table 4.)

Aggressor characteristics

From 2016, information related to the perceived aggressor or instigator of the V&A event was requested. This included the role of the aggressor (refer to Table 5) and a subjective assessment by the staff member reporting about additional factors which may have contributed to the situation; for example, that the patient was intoxicated, confused or having difficulty communicating with staff (refer to Table 6). Where the perceived aggressor was a patient, demographic data was obtained from the patient’s medical record (refer to Table 7).

View Tables 4–7.

Inconsistencies in data entry in formal reporting systems

An ongoing issue with V&A data collection was highlighted in the initial iteration of the study.

A review of officially collected data by monthly quantity was undertaken to allow comparison between the May reporting and that completed at other times. This identified the discrepancy between these months, with inconsistent reporting. While “Safety1st” was formally introduced in 2016, Figure 3 indicates that the staff reporting that occurred in the May campaigns were also not entered into this system. It was not until 2018, when the May data entry role was taken over by an ED clerical officer in an effort to improve the reporting rates, that information was also entered into “Safety1st”. Even with this assistance, discrepancies between the data collected from the “May – It’s Not Okay” campaign and that retrieved from the “Safety1st” system remain—this is likely due to different ways of categorising and inputting data. Overall, this suggests remaining difficulties in gathering accurate representation of staff incidents, whether due to failing to report in the absence of additional clerical support, or difficulties in retrieving an accurate representation of events from the current system.

Figure 3: Violence and aggression reporting by month (2015–2016) from "Safety1st".

Discussion

The interest in V&A reporting is part of the wider response to violence in healthcare. This has received international attention, and increasingly is highlighted within the New Zealand health system.[[15–16]] Our study shows that repeated monitoring can reveal the presence of V&A within an ED, which raises several concerns. Comparisons with other months in the year show much lower reporting rates, suggesting that barriers to reporting remain. This is in line with international literature, which also identifies difficulties in achieving consistent reporting.[[17–19]] The use of a single, targeted audit month offers a simple way to achieve a representative sample, and a more accurate estimate of any problem. As well as identifying the issues associated with reporting, the findings acknowledge the continued presence of violent events overtime. While this article does not allow for a detailed review of the responses to V&A that have been trialled alongside the audit, these have also included: the creation of an ED specific working group; collaborative engagements within the healthcare sector; hospital and DHB policy, pathway and process development; and ED specific innovations. It is possible that in the absence of such developments, the recorded events may have been even higher, and that the apparently “constant” level, despite the increasing ED presentations, actually represents a relative improvement to the baseline. Equally, it is possible that a degree of fatigue over time has seen a reduction in the reporting rate, and that the findings are under-representative. There is clearly a cumulative presence of verbal and physical violence within the working environment. This implies for the staff and organisation that there is a need to maintain a safe workplace and a healthy work environment. These results could inform changes, such as security staffing levels at times of predicted increased V&A.

Over the time that the study has run several trends have emerged, including that nurses report the highest incidence of V&A. This is in line with international research which identifies nurses and healthcare assistants at most risk of V&A;[[20]] however, willingness to report across all disciplines needs to be considered.[[9]] Evidence shows systemic under-reporting in nursing,[[21]] although other occupational groups may also find it difficult to recognise and report V&A. Further work highlighting this is necessary, with growing recognition of violence toward medical staff and reluctance to report this being recognised.[[ 22]] Future research could explore potential correlations between staff ethnicity, age and years of ED experience, and reported incidents.

The introduction of the Shorter Stays in Emergency Departments (SSED) 6-hour target in 2009 resulted in dramatic improvements in waiting times, but since their removal in 2017, there has been significant deterioration in these times.[[23]] It might be expected that the increase in waiting times may exacerbate the V&A reported. Recognition of characteristics within the patient group show connection to alcohol and drug use as associated factors, as well as a new patient group—describing those who present with a sense of entitlement and unrealistic expectations. Analysis of free text responses led to the addition of a new category description: “manipulative behaviour”. This included the emergent theme of “it’s all about me”—an identifiable group describing those who are demanding, threatening, and wanting to progress their own care regardless of other circumstances. This was typically associated with verbal abuse and intimidation, and at times physical intimidation.

Limitations

This study has several limitations. There were changes to the staff and to the audit instrument between the data collection periods. The participants effectively self-select by choosing to report the incidents of V&A. In the absence of external observation, it is difficult to confirm accuracy of the reporting, or the number of additional but unreported incidents that may occur. Data was not collected in 2017, as an in-depth staff survey into perceptions and attitudes around V&A was run during that year, and it was felt that both processes would be too burdensome for staff. The audit has continued over a period of years, and there is likely a degree of fatigue in terms of responder participation. It is possible, but highly unlikely, that the rates of V&A occurring in ED during May are different to other months of the year. There are no major public holidays or large events happening regularly during this month, and therefore V&A in May is likely similar to most other months—or perhaps less than certain months, such as December and January where alcohol-fuelled events are more common.

Conclusions

This study highlights that V&A remains an issue within the study site. Whether this is a reduction in what might otherwise have occurred, or an ongoing trend that has not responded to interventions, is unclear. However, it also indicates that the processes of the “May – It’s Not Okay” campaign offer a simple means of gaining insight into the realities of the problem, despite consistent under-reporting. There is clear need for further research into potential responses to V&A, the impact this has on staff and bystander wellbeing, and mechanisms for supporting affected staff as well as improving reporting systems.

Summary

Abstract

Aim

To examine reported levels of violence and aggression within a tertiary level emergency department in New Zealand, and to compare incident reporting within a dedicated yearly audit period to standard organisational reporting procedures.

Method

A prospective, longitudinal cohort study involving repeated yearly audits of violence and aggression reported by emergency department staff from 2014–2020.

Results

Episodes of violence and aggression were reported at high levels during audit months compared to standard reporting, suggesting current systems do not accurately reflect the presence of violence and aggression. Levels of reported violence and aggression remained relatively static over a seven-year period, despite increasing emergency department attendances. Most events reported involved verbal abuse from patients, and occurred on weekend and night shifts. A number of potentially contributing factors were identified.

Conclusion

Persistently higher levels of violence and aggression were reported during the targeted audit months, while reporting via the organisation’s formal system during the intervening months remained at low levels. Further research is essential to monitor trends, assess the effectiveness of interventions to improve reporting, modify factors contributing to violence and aggression, and to address the impact on staff and bystanders affected in emergency departments.

Author Information

Sandra Richardson: Nurse Researcher, Emergency Department, Christchurch Hospital, Canterbury District Health Board; Senior Lecturer, School of Health Sciences, Canterbury University. Paula Grainger: Nurse Coordinator Clinical Projects, Emergency Department, Christchurch Hospital, Canterbury District Health Board. Laura Joyce: Emergency Medicine Specialist, Emergency Department, Christchurch Hospital, Canterbury District Health Board; Senior Lecturer in Emergency Medicine, Department of Surgery, University of Otago, Christchurch.

Acknowledgements

The authors wish to acknowledge the contribution and commitment of all staff working in the Christchurch Hospital Emergency Department, and to commend their continued professionalism and hard work.

Correspondence

Sandra Richardson: c/-Emergency Department, Christchurch Hospital, 4 Riccarton Avenue, Christchurch 8011. 033640270.

Correspondence Email

Sandra.richardson@cdhb.health.nz

Competing Interests

Nil.

1) Marshall, B, Craig, A, Meyer, A. Registered nurses' attitudes towards, and experiences of, aggression and violence in the acute hospital setting. Kai Tiaki Nursing Research. 2017;8:31-36.

2) Baby M, Glue P, Carlyle D. 'Violence is not part of our job': a thematic analysis of psychiatric mental health nurses' experiences of patient assaults from a New Zealand perspective. Issues Ment Health Nurs. 2014 Sep;35(9):647-55. doi: 10.3109/01612840.2014.892552. PMID: 25162186.

3) Richardson SK, Grainger PC, Ardagh MW, Morrison R. Violence and aggression in the emergency department is under-reported and under-appreciated. N Z Med J. 2018 Jun 8;131(1476):50-58. PMID: 29879726.

4) Fedele R. Ground zero: standing up against violence in our healthcare sector. Aust Nurs Midwifery J. 2016 Jul;24(1):18-23. PMID: 29236431.

5) Pekurinen V, Willman L, Virtanen M, et al. Patient Aggression and the Wellbeing of Nurses: A Cross-Sectional Survey Study in Psychiatric and Non-Psychiatric Settings. Int J Environ Res Public Health. 2017 Oct 18;14(10):1245. doi: 10.3390/ijerph14101245. PMID: 29057802.

6) Shea T, Sheehan C, Donohue R, et al. Occupational Violence and Aggression Experienced by Nursing and Caring Professionals. J Nurs Scholarsh. 2017 Mar;49(2):236-243. doi: 10.1111/jnu.12272. Epub 2016 Nov 30. PMID: 27905189.

7) Phillips JP. Workplace Violence against Health Care Workers in the United States. N Engl J Med. 2016 Apr 28;374(17):1661-9. doi: 10.1056/NEJMra1501998. PMID: 27119238.

8) Pich JV, Kable A, Hazelton M. Antecedents and precipitants of patient-related violence in the emergency department: Results from the Australian VENT Study (Violence in Emergency Nursing and Triage). Australas Emerg Nurs J. 2017 Aug;20(3):107-113. doi: 10.1016/j.aenj.2017.05.005. Epub 2017 Jul 10. PMID: 28705687.

9) Copeland D, Henry M. Workplace Violence and Perceptions of Safety Among Emergency Department Staff Members: Experiences, Expectations, Tolerance, Reporting, and Recommendations. J Trauma Nurs. 2017 Mar/Apr;24(2):65-77. doi: 10.1097/JTN.0000000000000269. PMID: 28272178.

10) Han CY, Lin CC, Barnard A, et al. Workplace violence against emergency nurses in Taiwan: A phenomenographic study. Nurs Outlook. 2017 Jul-Aug;65(4):428-435. doi: 10.1016/j.outlook.2017.04.003. Epub 2017 Apr 13. PMID: 28487095.

11) Mikkola R, Huhtala H, Paavilainen E. Work-related fear and the threats of fear among emergency department nursing staff and physicians in Finland. J Clin Nurs. 2017 Oct;26(19-20):2953-2963. doi: 10.1111/jocn.13633. Epub 2017 Feb 9. PMID: 27805740.

12) Morken T, Baste V, Johnsen GE, Rypdal K, Palmstierna T, Johansen IH. The Staff Observation Aggression Scale - Revised (SOAS-R) - adjustment and validation for emergency primary health care. BMC Health Serv Res. 2018 May 8;18(1):335. doi: 10.1186/s12913-018-3157-z. PMID: 29739398.

13) Wong AH, Combellick J, Wispelwey BA, et al. The Patient Care Paradox: An Interprofessional Qualitative Study of Agitated Patient Care in the Emergency Department. Acad Emerg Med. 2017 Feb;24(2):226-235. doi: 10.1111/acem.13117. Epub 2017 Jan 30. PMID: 27743423.

14) Tadros A, Kiefer C. Violence in the Emergency Department: A Global Problem. Psychiatr Clin North Am. 2017 Sep;40(3):575-584. doi: 10.1016/j.psc.2017.05.016. Epub 2017 Jul 4. PMID: 28800811.

15) Brown K. Middlemore Hospital seeks to stop rising violence in emergency department. 24 April 2019. Radio NZ https://www.rnz.co.nz/news/national/387654/middlemore-hospital-seeks-to-stop-rising-violence-in-emergency-department

16) Donaldson RH. Alarming levels of ED violence now normalised and shrugged off, finds NZ study. 8 June 2018. Health Central.

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