23rd May 2014, Volume 127 Number 1394

Nicola Swain, Chris Gale, Rachel Greenwood

Working in the healthcare environment is a risk factor for violence, including patient violence or aggression.1,2 This is particularly well documented in nursing.3-6 Documented reasons for aggression include: factors attributable to the patient, the illness characteristics, the staff member, other people, poor communication and the environment.7
Aggression from patients is detrimental to health care workers and to the patient community, health care workers report high stress and dissatisfaction in their work,8 emotional exhaustion, depersonalisation and inefficacy9 and patients report a reduced level of care and autonomy when the relationship deteriorates.10
Research conducted in the UK comparing professional groups found nurses experienced more aggression than doctors.2 They reported high levels of aggression: 27% had been physically assaulted and 68% experienced verbal aggression.
The difference in physical assault by profession was striking, with 43% of nurses reporting physical assaults in the previous year compared to 14% of doctors. The same pattern was true for threatening behaviour. In both measures allied health staff reported the lowest levels of aggression. Allied health in this study was restricted to radiologists, physiotherapists and occupational therapists.
Patient violence has noted to be particularly high in certain clinical areas, specifically accident and emergency and psychiatric settings. One study reported 31% of nurses in an accident and emergency department had reported at least one physical assault in the preceding 6 months,11 another study found 56% had been assaulted in the previous 12 months.12
Similarly in psychiatry, Nolan13 reported that around 75% of mental health nurses had been exposed to violence during the previous year and 50% of psychiatrists had experienced violence in the preceding year.
Research of workplace aggression in nursing reports that male nurses are more likely to experience acts of aggression than females14 the same is true of community support workers.15
Little is known about the aggression experienced within a District Health Board (DHB) in New Zealand. Scales have been developed for the purpose of measuring workplace aggression including one that has been adjusted for use in New Zealand, the Perception of Patient Aggression Scale (POPAS-NZ).
Gale et al (2009)15 have previously used the POPAS-NZ to gather data on aggression in community support workers. The research reported that almost 20% of community support workers experienced verbal anger often/very often and nearly nine percent experienced physical aggression often/very often. Similarly, in a study of medical students it was reported that 67% had witnessed verbal aggression and 35% had witnessed physical aggression.16
We set out to examine the levels of aggression experienced by DHB hospital staff and consider whether experienced aggression varied according to health workers’ roles and places of work.

Methods

We recruited participants by contacting general managers of hospital units. We sought out mental health wards and units and also included: emergency medicine, neonatal intensive care, district nursing, rehabilitation, public health, and old age services. No surgical or general medical wards were included.
Following approval, service managers were contacted, and through them departmental managers. Data collection occurred at a time arranged by a meeting with the department manager. Staff were usually invited to participate at staff handover meetings or multidisciplinary meetings.
The participants were asked to fill in survey forms at the time of the meeting; the forms were collected and taken away for coding entry into a database. Particiapnts filled in the name, role, years of health employment, contact details and the POPAS-NZ survey. 100% participation was achieved from the 22 wards/units that were visited. See Figure 1.
Figure 1. Recruitment within the District Health Board
content01
Measures—The POPAS-NZ is a modification of the POPAS, developed by Oud17. The main modification has been an extension of the types of violence to include stalking and vexatious litigation. Previous work indicated that this was reasonably internally reliable, with a Cronbach alpha in two surveys of around 0.91.15 The POPAS-NZ consists of 12 questions each asking the respondent to rate how often each event may have happened to them over the previous year. Response categories range from 1(never) to 5 (frequently).
Statistics—Data was entered into a spreadsheet and analysed using PASW (formerly SPSS). Descriptive statistics are presented along with chi-squared statistics. Chi-squared were chosen because it compares counts of categorical responses between independent groups. A Bonferroni adjustment is necessary when multiple pair-wise tests are performed on a single data set to avoid false positives.

Results

Participants—Recruitment is outlined in Figure 1. 227 participants were recruited.
Table 1 shows numbers of participants by role and gender and also by years of service.
Table 1. Participation and average length of service by gender and role
Variables
Number of participants
Average length of service (years)
Total
Male
Female
Doctors
Nurses (total)
Registered
Enrolled
Allied health professionals
Clinical support staff
227
54
173
23
124
111
13
38
42
18.5
19.4
18.3
20.7
22.5
21.9
28.3
13
11.1
Prevalence and pattern of aggression experienced in the past year—Table 2 shows the frequency of the various types of patient aggression reported by staff. Responses have been summarised into occasionally/sometimes and often/frequently for ease of reading. Responses vary from 94% reporting experiencing verbal anger in the previous year to 10% reporting experiencing sexual assault.
Table 2. Frequency (%) distribution of respondents’ perception of the prevalence of various types of aggression
Variables
Never
Occasionally/sometimes
Often/Frequently
Verbal anger
Verbal threat
Humiliation
Physical aggression
Destructive behaviour
Attempted assault
Assault
Injury
Sexual harassment
Sexual assault
Stalking
Litigation
7
21
35
35
44
57
61
71
60
90
88
74
67
69
59
52
46
35
32
26
39
10
12
26
27
10
6
13
10
8
6
3
0
0
0
0
Table 3 shows ranges, medians and modes for the reported aggressive acts. Verbal anger, verbal threat, humiliation, physical aggression and destructive behaviour have medians above 0, so might be considered the commonly experienced. The other measures have medians below 1, which means they are not commonly experienced.
Table 3. Number of times of various types of aggressive behaviours on the POPAS-NZ in the past year
Variables
Range
Median
Mode
Verbal anger
Verbal threat
Humiliation
Physical aggression
Destructive behaviour
Attempted assault
Assault
Injury
Sexual harassment
Sexual assault
Stalking
Litigation
Never–frequent
Never–frequent
Never–frequent
Never–frequent
Never–frequent
Never–frequent
Never–frequent
Never–frequent
Never–often
Never–often
Never–frequent
Never–often
Sometimes
Occasionally
Occasionally
Occasionally
Occasionally
Never
Never
Never
Never
Never
Never
Never
Sometimes
Occasionally
Occasionally
Never
Never
Never
Never
Never
Never
Never
Never
Never
Aggression by gender—A Chi-squared (χ2) test was conducted between each POPAS question and gender: verbal anger (χ2=2.5, p=.62), verbal threat (χ2=10.3, p=04), humiliation (χ2=5.0, p=.29), physical aggression (χ2=3.8, p=.43), destructive behaviour (χ2=4.2, p=.38), attempted assault (χ2=12.5, p=.01), assault (χ2=12.6, p<=.01), injury (χ2=7.4, P=.11), sexual harassment (χ2=3.5, p=.34), sexual assault (χ2=3.4, p=.34), stalking (χ2=1.1, p=.79), litigation (χ2=6.7, p=.08). Although assault and attempted assault approach levels of significance, a Bonferroni correction suggests that we should use p<.004. Therefore, there appears to be no statistically significant relationship between each of the measures of aggression and gender.
Aggression by role—Participants were divided into one of four role groups: nurses, doctors, allied health and clinical support to see if different professional groups might experience differing levels of aggression.
Results suggest quite different patterns of aggression among the four occuptional groups. For illustrative purposes the two highest frequency aggressive behaviours (verbal aggression and physical aggression) are shown.
Around a third of both nurses and clinical support workers experience verbal aggression often or frequently (see Table 4). Clinical support workers and nurses also reported the higest rates of physical aggression (see Table 5).
Table 4. Percentage POPAS-NZ scores by role for verbal aggression
Role
Never
Occasionally/sometimes
Often/frequently
n
Physicians
4.5
81.9
13.6
22
Nurses
2.5
63.1
34.4
122
Allied health
18.0
74.0
8.0
50
Clinical support
9.1
57.6
33.3
33
Table 5. Percentage POPAS-NZ scores by role for physical aggression
Role
Never
Occasionally/sometimes
Often/frequently
n
Physicians
Nurses
Allied health
Clinical support
36.4
26.2
58.0
30.3
59.1
58.2
36.0
48.5
4.5
15.6
4.0
21.2
22
122
50
33
Chi-squared tests show statistically significant differences in responses by role for all measures of aggression except sexual harassment, sexual assault, destructive behaviour, and stalking (p<.004), which are among the lower frequency events. Verbal anger (χ2=45.2, p<.000), verbal threat (χ2=74.3, p<.000), humiliation (χ2=54.1, p<.000), physical aggression (χ2=35.9, p=.003), destructive behaviour (χ2=31.6, p=.011), attempted assault (χ2=43.9, p<.000), assault (χ2=47.6, p<.000), injury (χ2=35.7, P=.003), sexual harassment (χ2=12.1, p=.44), sexual assault (χ2=7.4, p=.83), stalking (χ2=15.4, p=.22), litigation (χ2=20.5, p=.06).
Aggression by department—Data was divided into mental health wards and units (63%) and other hospital wards and units (37%). Chi-squared tests revealed differences between the two patient groups in destructive behaviour (χ2=20.7. p<0.001) and physical aggression (χ2=24.2. p<.001).
All other questions relating to aggression experienced (including actual assault) do not systematically vary according to whether they are mental health units or not. A mental health ward/unit has more destructive behaviour and physical aggression but on all other measures is similar to other hospital wards/units.

Discussion

The aim of this study was to report on aggression experienced by the healthcare workforce in New Zealand. This was done by using a standardised survey instrument, across a hospital setting. Results show significant levels of aggression reported by healthcare workers.
Interestingly, more aggression was reported in the hospital setting than had previously been reported by community support workers15 and medical students16 using this tool in New Zealand. The rates are considerably higher than those reported in a UK general hospital where 27% were physically assaulted over the preceding year,2 compared to 38% in the past year in the present study. In a review of international nursing studies, 64.% reported ever being physically assaulted by a patient,6
The rates of assault in the healthcare workplace in New Zealand are higher than the lifetime incidences of interpersonal violence in New Zealand, which has been recognised as a national priority. Lifetime rates of interpersonal violence reported by women range from 17–19%.18 That 38% of our healthcare workforce report experiencing an assault in the previous year could be seen as a situation to which urgent attention should be paid. Inexperience does not appear to be a causal factor with the average experience of the healthcare worker being 18 years.
Prevalence of assault over working lives might be much higher than our figure of 38% in previous year, (although recall bias can favour recall of the most recent past) as reported at 64% in the review by Spector, Zhou and Che (2013).
Consistent with previous studies there were also significant differences in the aggression experienced and the professional group surveyed. Nurses experience the greatest levels of aggression, followed by doctors and clinical support, with allied health experiencing the lowest levels. Winstanley and Whittington (2004) also reported that nurses experienced the most aggression, followed by doctors and then allied health.
This study has added the group of clinical support staff and found that they too are experiencing high levels of aggression. The present study had a wider definition of allied health than the previous study but it did not change its position as least likely role to report aggression. There may be some confounding with hours of patient contact, which could be controlled for in future studies. However, the between group differences are sufficiently large that this is unlikely to fully account for them.
There were no effects of gender of the healthcare worker on the experience of aggression. Previous research had suggested that male nurses experience more aggression than female nurses14 and likewise male community support workers experience more aggression than females.15 It might be that analysis of gender by occupation is needed to elaborate these differences.
There are also few effects of working in mental health compared to other areas of the hospital. The data suggest that destructive behaviour and physical aggression are higher in mental health wards/units but no other measures of aggression show significant differences. This is also in contrast to previous finding which mental health is a particularly risky area to work in13 but again the relationship might be a more complex interaction of workplace by role as allied health have the lowest levels of aggression and many (e.g. Psychologists) are also working in mental health. Those wards not sampled (medical and surgical) could possibly represent lower risk workplaces.
The study was generally well received and supported by the staff. A good participation rate was achieved using the recruitment method of attending departmental meetings. However, there are several limitations of the present research. This survey did not reach all areas of the hospital and so does not represent the experience of all of the staff employed by the DHB. There are no medical and surgical wards included in this survey; coverage could be improved for future surveys.
In summary, this study used a tool (POPAS-NZ) specifically designed to measure aggression in the healthcare workforce in a hospital in New Zealand. Significant levels of workplace aggression were experienced in a DHB environment. When roles were considered it was found that nurses were most at risk of aggression, which suggests targeted training might be considered highest priority for nurses but should also be considered for those in support roles working in a hospital. Department and gender were found to be less important predictors of aggression.
While it is important that workplaces support staff who are experiencing aggression, it is also possible to improve training to reduce aggression. Previous research in New Zealand has correlated a communication style with risk of aggression.15 This is a modifiable component of the patient interaction and as such has potential for intervention. Future research might examine if communication skill interventions for staff could reduce the experience of aggression.

Summary

Most hospital staff experience violence or aggression from patients in New Zealand. This is worst for nurses but happens to most staff. More than one-third of staff get physically assaulted each year, resulting in physical injury for just under one-third of those. This is higher than our rates of domestic violence, but nothing is being done.

Abstract

Aim

Working in a healthcare environment is a known risk factor for violence. Patient aggression towards staff is often present in a hospital setting but the extent, type and variation among various occupations and roles are not known.

Method

This research examines the type and frequency of aggression experienced by healthcare staff, using a previously used measure the POPAS-NZ, which is a short pen and paper survey. Responses were gathered from 227 people working in a single district health board.

Results

Responses showed verbal anger was experienced by 93% of healthcare workers in the previous year and physical aggression was experienced by 65% of respondents. Also, 38% of staff reported experiencing a physical assault in the previous year. When analysed by role it was found that nurses and support staff experienced the greatest number of aggressive incidents compared to doctors and allied health staff. No effects of gender of the healthcare worker were found. Psychiatric units showed greater levels of destructive behaviour and attempted assaults but were similar to other areas of the hospital on all other measures.

Conclusion

These results demonstrate many hospital staff, of all roles and workplaces experience aggression on a frequent basis. Implications for staff training are discussed.

Author Information

Nicola Swain, Senior Lecturer – Behavioural Science, Department of Psychological Medicine, Dunedin School of Medicine, University of Otago, Dunedin; Chris Gale, Senior Lecturer – Psychiatry, Department of Psychological Medicine, Dunedin School of Medicine, University of Otago, Dunedin; Rachel Greenwood, Department of Psychological Medicine, Dunedin School of Medicine, University of Otago, Dunedin

Correspondence

Dr Nicola Swain, Department of Psychological Medicine, Dunedin School of Medicine, University of Otago, Cumberland Street, Dunedin 9054, New Zealand.

Correspondence Email

nicola.swain@otago.ac.nz

Competing Interests

Nil

References

1.       Carter R. High risk of violence against nurses. Nursing Management. 2000;6:5.

2.       Winstanley S, Whittington R. Aggression towards health care staff in a UK general hospital: variation among professions and departments. Journal of Clinical Nursing. 2004;13(1):3-10.

3.       Jackson D, Clare J, Mannix J. Who would want to be a nurse? Violence in the workplace–a factor in recruitment and retention. Journal of Nursing Management. 2002;10(1):13-20.

4.       Wells J, Bowers L. How prevalent is violence towards nurses working in general hospitals in the UK? Journal of Advanced Nursing. 2002;39(3):230-240.

5.       Camerino D, Estryn-Behar M, Conway PM, et al. Work-related factors and violence among nursing staff in the European NEXT study: a longitudinal cohort study. International Journal of Nursing Studies. 2008;45(1):35-50.

6.       Spector PE. Zhou ZE. Che XX. Nurse exposure to physical and nonphysical violence, bullying, and sexual harassment: A quantitative review. International Journal of Nursing Studies. 2014; 51(1):72-84.

7.       Duxbury J. Whittington R. Causes and management of patient aggression and violence: staff and patient perspectives. Journal of Advanced Nursing. 2005;50(5):469-78.

8.       Finnema EJ, Dassen T, Halfens R. Aggression in psychiatry: a qualitative study focusing on the characterization and perception of patient aggression by nurses working on psychiatric wards. Journal of Advanced Nursing. 2006;19(6):1088-95.

9.       Gascon S, Leiter MP, Pereira JP, et al. The role of aggressions suffered by healthcare workers as predictors of burnout. Journal of Clinical Nursing. 2013; 22(21-22):3120-3129.

10.    Cutcliffe JR. Qualified nurses' lived experience of violence perpetrated by individuals suffering from enduring mental health problems: a hermeneutic study. International Journal of Nursing Studies. 1999;36(2):105-16.

11.    Pich J, Hazelton M, Sundin D, Kable A. Patientrelated violence against emergency department nurses. Nursing & Health Sciences. 2010;12(2):268-274.

12.    Erickson L, Williams-Evans SA. Attitudes of emergency nurses regarding patient assaults. Journal of Emergency Nursing. 2000;26(3):210-215.

13.    Nolan P, Dallender J, Soares J, et al. Violence in mental health care: the experiences of mental health nurses and psychiatrists. Journal of Advanced Nursing. 1999;30(4):934-941.

14.    Farrell GA, Bobrowski C, Bobrowski P. Scoping workplace aggression in nursing: findings from an Australian study. Journal of Advanced Nursing. 2006;55(6):778-787.

15.    Gale C, Hannah A, Swain N, et al. Patient aggression perceived by community support workers. Australasian Psychiatry. 2009;17(6):497-501.

16.    MacKay J, Hannah A. Medical students' experiences of patient aggression and communication style. Australasian Psychiatry. 2009;17(1):59-60.

17.    Oud N. Internal report. POPAS Ervaringen van psychiatrische hulpverleners met agressief gedrag. 2001:1–2

18.    Fanslow JL, Robinson, EM. Violence against women in New Zealand: prevalence and health consequences. New Zealand Medical Journal 2004;117(1206). http://journal.nzma.org.nz/journal/117-1206/1173/content.pdf