61
Work 51 (2015) 61–66 DOI 10.3233/WOR-141889 IOS Press
Development of the Personal Workplace Safety Instrument for Emergency Nurses Christian Burchill Office of Research and Innovation, Nursing Institute, Cleveland Clinic T3-15, 9500 Euclid Ave. Cleveland, OH 44195, USA Tel.: +1 216 445 9317; E-mail: [email protected]
Received 12 February 2013 Accepted 2 November 2013
Abstract. BACKGROUND: Much of the research on violence committed by patients and family members against healthcare providers in the hospital focus on the frequency and severity of incidents plus personal, perpetrator, and hospital characteristics. The literature lacks research on those factors that make healthcare providers in hospitals feel safe from workplace violence committed by patients and family members. OBJECTIVE: The objective of this project is to design an instrument to measure the perceptions of personal safety of emergency nurses in the workplace. METHODS: To develop the Personal Workplace Safety Instrument for Emergency Nurses (PWSI EN) an extensive review of the literature was conducted and recurrent themes identified. Informal focus groups of emergency nurses and discussions with administrators were conducted to confirm these themes. A review by workplace violence experts and a pilot test with emergency nurses was conducted. RESULTS: The instrument has 31 Likert-scale items to measure the factors of workplace countermeasures, patient-nurse interactions, and administrative and judicial support measures. Fifteen demographic questions were developed to measure characteristics of the nurse and hospital. Results of the expert panel review yielded high content validity (cumulative validity index = 0.98). CONCLUSION: The instrument is valid to measure the perceptions of personal safety in the workplace with emergency nurses. Keywords: Workplace violence, instrument development, safety
1. Introduction What were once viewed as safe havens from the violence of the outside world, hospitals have come to reflect the violent nature of the rest of society. The Occupational Health and Safety Administration (OSHA) define workplace violence as, “. . . any act or threat of physical violence, harassment, intimidation, or other threatening disruptive behavior that occurs at the work site. It ranges from threats and verbal abuse to physical assaults and even homicide.” [1]. According to the US Department of Labor, Bureau of Labor Statistics, in 2011 the healthcare and social service sector accounted for 55% of private industry
violence-related injuries that required time away from work [2]. The Joint Commission, the largest accrediting body for healthcare organizations in the United States, issued a sentinel event alert in June 2010 reporting, “Since 2004, the sentinel event database indicates significant increases in reports of assault, rape and homicide. . . ” against healthcare workers [3]. Violence committed by patients or family members on emergency nurses in the United States has plateaued after many years of climbing [4]. Workplace violence in the healthcare setting is not limited to the United States. There is a growing body of evidence that workplace violence in the healthcare setting is a global problem [5–11]. The problem is so
c 2015 – IOS Press and the authors. All rights reserved 1051-9815/15/$35.00
62
C. Burchill / Development of the Personal Workplace Safety Instrument for Emergency Nurses
widespread that the International Council of Nurses issued this statement: “The increasing incidents of abuse and violence in health care settings are interfering with the provision of quality care and jeopardizing the personal dignity and self-value of health personnel.” [12] There is research to support this statement [13]. Much of the research on this global problem has been conducted in the emergency department setting. The research shows that, regardless of the country where the study is conducted, nurses are the most common victims, feel the least safe, and are the usual targets of violence committed by patients and visitors compared to other emergency department personnel [5–9,11,14,15]. The majority of the literature on workplace violence committed by patients or visitors is survey research that focuses on identifying the prevalence and type of violence that emergency nurses face in the workplace [4–9,11,14]. In some studies, organizational factors are also examined [4,14,15]. It would seem that we have a fairly good understanding of the severity and prevalence of workplace violence against emergency nurses, and some understanding of the organizational factors that may impact workplace violence against emergency nurses. An area lacking in the literature is an instrument to measure emergency nurses perceptions of safety in their place of work. The purpose of this study is to develop such an instrument.
2. Methods In order to better understand factors that may influence perceptions of workplace safety for emergency nurses, the databases CINAHL, Pub Med Plus, and ISI Web of Science were searched for the past ten years using the keywords “workplace violence,” “hospital,” and “emergency department”. This yielded a total of seventeen research article, two review articles, and two reports from around the world. Recurrent themes identified from this review formed the foundational basis for survey item generation. Four possible conceptual domains were identified from the literature: countermeasures, patient-nurse interaction, administrative and judicial support, and personal and hospital demographics. Clinical emergency nurses from one major medical center were then asked to volunteer to participate in a brief, informal focus group in which the following statement was used to solicit responses: “When you
were either the victim or witness to workplace violence committed by patients or visitors, what made you feel more or less safe?” Three groups of four nurses agreed to participate. The interviewer wrote down their initial statement verbatim. The interviewer summarized responses and that summary was confirmed with the respondent prior to writing it down. A thematic structure from focus group data emerged using a content analysis. The three themes matched the conceptual domains and these themes guided the generation of the 30-item statements included in the survey. The following sections provide support from the focus groups and the literature for each conceptual domain. 2.1. Countermeasures Workplace violence countermeasures are those resources put in place by the hospital to prevent violent behavior by patients and visitors. The availability and effectiveness of security is one countermeasure that has been identified as a factor in workplace safety [16–18]. Training in handling violent behavior is another countermeasure that has been identified [14,17,19]. Design of the physical environment of the emergency department has also been identified as a possible countermeasure [4]. One of the themes identified by the focus groups of emergency nurses was the availability and abilities of the security officers employed by the hospital. Statements such as, “We need security in the department 24/7,” and “I pushed the panic button but it took security a long time to come,” were common. Benham et al. reported in their survey of academic emergency departments that security was available for most emergency departments but, in general, were not available in patient care areas. When security officers are stationed in the emergency department, incidence of violence decrease [4,14,16]. When security officers did respond, according to focus group participants, they were not always helpful. “I got hand sanitizer thrown in my face and they just stood there and let the guy walk out,” was one example a triage nurse gave about her experience with workplace violence and the security force’s response. “They just stood there while she yelled obscenities at me,” was another response to questions about security’s effectiveness in handling an irate family member. “We never have a problem when Officer ____ is working in the department,” also came up repeatedly. These comments are supported by findings from two qualitative research studies on workplace violence against emer-
C. Burchill / Development of the Personal Workplace Safety Instrument for Emergency Nurses
gency nurses [17,18]. Both studies report that emergency nurses want security officers to control access to the department and have a positive effect with violent patients and visitors. Unfortunately, sometimes the security officers have a negative effect on the situation [18]. Training in de-escalation and personal safety techniques should increase emergency nurses’ perceptions of workplace safety. Training in these techniques, when it is offered by a hospital, is frequently not mandatory for emergency nurses or hospital security officers [4,15,19,20]. Training in these techniques has been shown to decrease the odds of verbal abuse suffered by emergency nurses but not to a statistically significant level [4]. In a large-scale study of workplace violence in emergency departments, Kansagra et al. report that emergency department staff members that received training in violence prevention felt safer than those that had not, though not quite reaching statistical significance in the final analysis [14]. Finally, departmental design has been shown to be a useful countermeasure to workplace violence [4]. Screening for weapons with a metal detector or an xray machine upon entry to the ED waiting room has not been shown to be the most effective countermeasure or increase a sense of safety among the staff [16,17]. Less than half of the emergency departments in a large-scale study of safety measures used by emergency departments are using some form of weapon detection system [16]. Departments that have panic buttons and enclosed nurses stations have been associated with lower rates of verbal abuse by patients and visitors; and, thus, a greater sense of security for emergency nurses [4,14]. Based on the focus group data and the review of the relevant literature, one item was added to rate the perception of the emergency department’s physical plant design for workplace safety. A sample of the instrument items is provided in Table 1. 2.2. Patient-nurse interaction Expectations of patients and their family members of their emergency department experience may be influenced by their subjective state of health, cognitive abilities, and previous experiences and interactions with emergency care providers [21]. The interactions that occur with emergency care providers can greatly influence patient and visitor behavior [4,21]. The idea that patient expectations and interactions may influence a nurse’s perception of personal safety in the emergency department was identified in focus groups.
63
“Patients come here thinking they are the sickest patient, even if they just have a cold,” was one example given by a focus group participant. “I try my best to provide high quality care and excellent customer service in triage but on a really busy night it can be really difficult,” said a nurse referring to her time triaging patients in the waiting room. Some focus group nurses felt that a realistic expectation on the patient’s part and a positive interaction made them feel safer. Interactions with patients and their presenting state have an impact on emergency nurses’ perceptions of their workplace safety [21]. In particular, those patients with psychiatric complaints, who are intoxicated, who present in an emotionally charged state, or who have an impression of poor quality of care in the emergency department can make emergency nurses feel vulnerable to workplace violence [5,17,21,22]. Sample instrument items aimed at examining the relationship between patient-nurse interaction and perception of personal safety are listed in Table 1. 2.3. Hospital and judicial support Workplace violence incidents in emergency departments are dramatically underreported [4,21]. There are many reasons why emergency nurses don’t report workplace violence, including cumbersome reporting systems, lack of response when reported, and reporting it verbally to a supervisor or colleague [4,15]. Research suggests that emergency nurses feel that incident reporting systems are often cumbersome, which decreases chances that emergency nurses will complete the forms [10,24]. User-friendly incident reporting systems are recommended to improve reporting [10,13,23,24]. Another reason that emergency nurses underreport workplace violence is the response, or lack of response, from department and hospital administrators. When emergency nurses do report violence, they are generally dissatisfied with the response from their department or hospital administrator’s actions towards the patient or the investigation into the incident [4,5, 7,8,10,13]. Nurses feel that hospital administrators are the least interested in this problem of all those involved in the problem [5,13]. Emergency nurse focus group participants highlighted some of the factors why they don’t report. “Nothing’s going to change if I report it,” and “I can’t be bothered filling out that long form after an incident. I just want to forget about it,” were comments received from participants. “My manager wanted me to clock
64
C. Burchill / Development of the Personal Workplace Safety Instrument for Emergency Nurses Table 1 Sample of the instrument items
Factor Workplace countermeasures
Instrument item – There are sufficient security officers working in the ED at all times to ensure the safety of coworkers, my patients, their family, and me. – My emergency department has been designed and outfitted to ensure my safety while at work. – Security officers will assist me in trying to manage unacceptable behavior from a patient or family member.
Patient expectations and interactions
– People come to the ED with unrealistic expectations that causes them to act in ways that would be unacceptable in the general public. – Explaining why people are waiting and how the ED system works usually defuses some of the patient or family member aggressiveness. – I feel justified in asking patients and family members to stop using abusive language around me.
Organizational support
– Hospital administration would be more responsive to a threat or violent act committed against a physician than against another member of the health care team. – My physician colleagues will stand behind me when I report violent behavior or threats by a patient or family member. – The judicial system will prosecute to the fullest extent of the law anyone who assaults me.
out before I took the time to fill out the incident report,” said another participant. Some participants also expressed concern with the consequences of filing a police report. One emergency nurse said, “I’ve tried to press charges before and it seemed that the police and district attorney’s office didn’t take it too seriously.” Other participants expressed fear of retaliation from patients, visitors, or hospital administration if they report an incident of workplace violence. Table 1 provides sample items from the instrument related to the factor hospital and judicial support. 2.4. Personal and hospital demographics Certain demographic factors may have a relationship to perception of workplace safety for emergency nurses. Most survey research done on workplace violence against emergency nurses includes some personal, educational, and occupational characteristics. Age of the nurse has been associated with experiencing workplace violence, though with conflicting results. One study found that older age increased the risk for workplace violence [15] while two other studies found that younger age was a risk factor for workplace violence [9,13]. In another study, the researchers reported that more years of experience (tenure) increased the risk for experiencing workplace violence [15]. Gender is reported as a risk factor for experiencing workplace violence. Men are frequently the victims of workplace violence, though the reason for this is unclear especially considering that nursing remains a female dominated profession [8,9,14–16,25]. Racial background has also been studied but the relationship to workplace
violence and safety is unclear [14,15]. Additional demographic characteristics included in the survey but not studied in most research are highest educational level achieved, usual shift worked, employment status, previous experience with workplace violence, and previous experience with workplace violence committed by a co-worker. Determining if participants had training in deescalation and personal safety may have a relationship with feelings of personal safety in the workplace. Training in these techniques has been shown to have a positive effect on workplace violence in some studies [14,25], while another study found no relationship [13]. Previous experience with violence or violent crime not associated with the workplace has also been shown to be a risk factor for experiencing violence in the workplace [15]. This experience may or may not have an impact on perceptions of safety in the workplace but has not been explored in the literature.
3. Validity and pilot testing Using the focus group notes and the literature review as a guide, thirty statements were generated that could be related to emergency nurse perceptions of safety from workplace violence committed by patients and visitors. This would become the Personal Workplace Safety Instrument for Emergency Nurses (PWSI EN). Following the recommendations of content validity experts, three nationally recognized experts, two NIOSH funded researchers on this topic plus a past president of the Emergency Nurses Association, were asked to independently review the statements for clarity and score
C. Burchill / Development of the Personal Workplace Safety Instrument for Emergency Nurses
each statement as either, “not at all relevant,” “somewhat relevant,” “relevant,” or “highly relevant.” A content validity score was calculated by taking the number of experts that rated each statement as, “relevant,” or, “highly relevant” divided by the number of experts. Twenty-nine of thirty statements were rated as, “relevant,” or, “highly relevant.” The cumulative content validity score obtained was 0.98 [26]. The item rated by one expert as, “not at all relevant,” was re-written based on their recommendation. The administrators of an urban, quaternary medical center agreed to allow pilot testing of the instrument. IRB approval was obtained. Seventy-three percent of the full-, part-, and per diem-time emergency nurses volunteered to participate. The participants provided feedback regarding ease of use, relevance, and clarity. Based on feedback, a statement was added to the demographic section that asks participants to rate their fearfulness while at work.
4. Conclusion Much research has been conducted on workplace violence experienced by emergency nurses. Most research examines the frequency, severity, and personal and hospital characteristics associated with workplace violence. Little research exists on those factors that effect emergency nurses’ perceptions of safety from workplace violence committed by patients and visitors. The PWSI EN is a valid instrument to measure nurses’ perceptions of safety in relation to workplace violence Further testing of the instrument is planned prior to a larger study using this instrument. Correlational statistics will be used to determine internal consistency reliability for each item and sub-scale. Construct validity will be determined by factor analysis methods. Descriptive, parametric, and nonparametric statistical analyses will be conducted using the demographic data.
[3]
[4]
[5]
[6]
[7]
[8]
[9]
[10]
[11]
[12]
[13]
[14]
[15]
[16]
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Occupational Safety and Health Administration. Workplace Violence. [Internet]. [cited 30 Aug 2012]. Available from: http://www.osha.gov/SLTC/workplaceviolence/. US Department of Labor, Bureau of Labor Statistics. Occupational injuries/illnesses and fatal injuries profiles. [Internet]. [cited 24 Augusts 2013]. Available from: http://data. bls.gov/gqt/RequestData.
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The Joint Commission. Preventing violence in the workplace. Sentinel event alert, Issue 45. [Internet]. 2010 [cited 30 Aug 2012]. Available from: http://jointcommission.org/sentinel_ event_alert_issue_45_preventing_violence_in_the_health_ care_setting_/. Emergency Nurses Association, Institute for Emergency Nursing Research. Emergency department violence surveillance survey study. [Internet]. 2011 [cited 30 Aug 2012]. Available from: http://www.ena.org/IENR/Pages/Workplace Violence.aspx doi: 10.1111/j.1466-7657.2010.00834.x. AbuAlRub RF, Hasan Al-Asmar A. Physical violence in the workplace among Jordanian hospital nurses. J Transcult Nurs 2011 22: 157 originally published online 10 February 2011. doi: 10.1177/1043659610395769. Alameddine M, Kazzi A, El-Jardali F, Dimassi H, Maalouf S. Occupational violence at Lebanese emergency departments: Prevalence, characteristics, and associated factors. J Occup Health 2011; 53: 455-464. Chapman R, Styles I. An epidemic of abuse and violence: Nurse on the front line. Accident and Emergency Nursing 2006; 14: 245-249. doi: 10.1016/j.aaen.2006.08.004. Esmaeilpour M, Salsali M, Ahmadi F. Workplace violence against Iranian nurses working in emergency departments. Int Nurs Rev. 2010; 58: 130-137. Franz S, Zeh A, Schablon A, Kuhnert S, Nienhaud A. Aggression and violence against health care workers in Germany – a cross sectional retrospective survey. BMC Health Services Research 2010 10:51. doi: 10.1186/1472-6963-10-51. Landau S, Bendalak Y. Personnel exposure to violence in hospital emergency wards: A routine activity approach. Aggressive Behavior 2008; 34: 88-103. doi: 10.1002/ab.20214. Talas MS, Kocaoz S, Akguc S. A survey of violence against staff working in the emergency department in Ankara, Turkey. Asian Nursing Research 2011; 5: 197-203. doi: 10.1016/j.anr. 2011.11.001. International Council of Nurses. Guidelines on coping with violence in the workplace. [Internet]. 9 Mar 2012 [cited 30 Aug 2012]. Available from: http://www.icn.ch/publications/ guidelines/. Gates D, Gillespie G, Succop P. Violence against nurses and its impact on stress and productivity. Nursing Economic$ 2011; 29: 59-66. Kansagra SM, Rao SR, Sullivan AF, Gordon JA, Magid, DJ, Kaushal, R, et al. A survey of workplace violence across 65 U.S. emergency departments. Academic Emergency Medicine 2008; 15: 1268-1274. doi: 10.1111/j.1553-2712. 2008.00282.x. Campbell J, Messing J, Kub J, Agnew J, Fitzgerald S, Fowler B, Sheridan D, Lindauer C, Deaton J, Bolyard R. Workplace violence: Prevalence and risk factors in the Safe at Work study. Journal of Occupational and Environmental Medicine 2011; 53: 82-89. Benham M, Tillotson R, Davis S, Hobbs, G. Violence in the emergency department: A national survey of emergency medicine residents and attending physicians. The journal of EmergencyMedicine 2011; 40: 565-579. doi: 10.1016/j. jemermed.2009.11.007. Catlette M. A descriptive study of the perceptions of workplace violence and safety strategies of nurses working in level 1 trauma centers. Journal of Emergency Nursing 2005; 31: 519-525. Gillespie G, Gates D, Miller M, Howard, P. Emergency department workers’ perceptions of security officers’ effective-
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C. Burchill / Development of the Personal Workplace Safety Instrument for Emergency Nurses ness during violent events. WORK 2012; 42: 21-27. doi: 10. 3233/WOR-2012-1327. Deans C. The effectiveness of a training program for emergency department nurses in managing violent situations. Australian Journal of Advanced Nursing 2004; 4: 17-22. Martindell D. National violence training standards for hospital security officers are overdue. Pennsylvania Patient Safety Advisory 2012; 9: 65-66. Luck L, Jackson D, Usher K. Innocent or culpable? Meanings that emergency department nurses ascribe to individual acts of violence. Journal of Clinical Nursing 2007; 1071-78. doi: 10.1111/j.1365-2702.2006.01870.x. Pich J, Hazelton M, Sundin D, Kable A. Patient-related violence at triage: A qualitative descriptive study. International Emergency Nursing 2011; 19: 12-19. doi: 10.1016/j.enj.2009. 11.007.
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Lau J, Magarey J, Wiechula R. Violence in the emergency department: An ethnographic study. International Emergency Nursing 2012; 20: 69-75. doi: 10.1016/j.ienj.2011.07.006. Gillespie, GL. Consequences of violence exposures by emergency nurses. Journal of Aggression, Maltreatment & Trauma 2008; 16: 409-418. doi: 10.1080/10926770801926583. Arnetz J, Aranyos D, Ager J, Upfal M. Development and application of a population-based system for workplace violence surveillance in hospitals. American Journal of Industrial Medicine 2011; 54: 925-934. doi: 10.1002/ajim.20984. Polit DF, Beck CT. The content validity index: Are you sure you know what’s being reported? Critique and recommendations. Research in Nursing and Health 2006; 29: 489-487.
Work 51 (2015) 61–66 DOI 10.3233/WOR-141889 IOS Press
Development of the Personal Workplace Safety Instrument for Emergency Nurses Christian Burchill Office of Research and Innovation, Nursing Institute, Cleveland Clinic T3-15, 9500 Euclid Ave. Cleveland, OH 44195, USA Tel.: +1 216 445 9317; E-mail: [email protected]
Received 12 February 2013 Accepted 2 November 2013
Abstract. BACKGROUND: Much of the research on violence committed by patients and family members against healthcare providers in the hospital focus on the frequency and severity of incidents plus personal, perpetrator, and hospital characteristics. The literature lacks research on those factors that make healthcare providers in hospitals feel safe from workplace violence committed by patients and family members. OBJECTIVE: The objective of this project is to design an instrument to measure the perceptions of personal safety of emergency nurses in the workplace. METHODS: To develop the Personal Workplace Safety Instrument for Emergency Nurses (PWSI EN) an extensive review of the literature was conducted and recurrent themes identified. Informal focus groups of emergency nurses and discussions with administrators were conducted to confirm these themes. A review by workplace violence experts and a pilot test with emergency nurses was conducted. RESULTS: The instrument has 31 Likert-scale items to measure the factors of workplace countermeasures, patient-nurse interactions, and administrative and judicial support measures. Fifteen demographic questions were developed to measure characteristics of the nurse and hospital. Results of the expert panel review yielded high content validity (cumulative validity index = 0.98). CONCLUSION: The instrument is valid to measure the perceptions of personal safety in the workplace with emergency nurses. Keywords: Workplace violence, instrument development, safety
1. Introduction What were once viewed as safe havens from the violence of the outside world, hospitals have come to reflect the violent nature of the rest of society. The Occupational Health and Safety Administration (OSHA) define workplace violence as, “. . . any act or threat of physical violence, harassment, intimidation, or other threatening disruptive behavior that occurs at the work site. It ranges from threats and verbal abuse to physical assaults and even homicide.” [1]. According to the US Department of Labor, Bureau of Labor Statistics, in 2011 the healthcare and social service sector accounted for 55% of private industry
violence-related injuries that required time away from work [2]. The Joint Commission, the largest accrediting body for healthcare organizations in the United States, issued a sentinel event alert in June 2010 reporting, “Since 2004, the sentinel event database indicates significant increases in reports of assault, rape and homicide. . . ” against healthcare workers [3]. Violence committed by patients or family members on emergency nurses in the United States has plateaued after many years of climbing [4]. Workplace violence in the healthcare setting is not limited to the United States. There is a growing body of evidence that workplace violence in the healthcare setting is a global problem [5–11]. The problem is so
c 2015 – IOS Press and the authors. All rights reserved 1051-9815/15/$35.00
62
C. Burchill / Development of the Personal Workplace Safety Instrument for Emergency Nurses
widespread that the International Council of Nurses issued this statement: “The increasing incidents of abuse and violence in health care settings are interfering with the provision of quality care and jeopardizing the personal dignity and self-value of health personnel.” [12] There is research to support this statement [13]. Much of the research on this global problem has been conducted in the emergency department setting. The research shows that, regardless of the country where the study is conducted, nurses are the most common victims, feel the least safe, and are the usual targets of violence committed by patients and visitors compared to other emergency department personnel [5–9,11,14,15]. The majority of the literature on workplace violence committed by patients or visitors is survey research that focuses on identifying the prevalence and type of violence that emergency nurses face in the workplace [4–9,11,14]. In some studies, organizational factors are also examined [4,14,15]. It would seem that we have a fairly good understanding of the severity and prevalence of workplace violence against emergency nurses, and some understanding of the organizational factors that may impact workplace violence against emergency nurses. An area lacking in the literature is an instrument to measure emergency nurses perceptions of safety in their place of work. The purpose of this study is to develop such an instrument.
2. Methods In order to better understand factors that may influence perceptions of workplace safety for emergency nurses, the databases CINAHL, Pub Med Plus, and ISI Web of Science were searched for the past ten years using the keywords “workplace violence,” “hospital,” and “emergency department”. This yielded a total of seventeen research article, two review articles, and two reports from around the world. Recurrent themes identified from this review formed the foundational basis for survey item generation. Four possible conceptual domains were identified from the literature: countermeasures, patient-nurse interaction, administrative and judicial support, and personal and hospital demographics. Clinical emergency nurses from one major medical center were then asked to volunteer to participate in a brief, informal focus group in which the following statement was used to solicit responses: “When you
were either the victim or witness to workplace violence committed by patients or visitors, what made you feel more or less safe?” Three groups of four nurses agreed to participate. The interviewer wrote down their initial statement verbatim. The interviewer summarized responses and that summary was confirmed with the respondent prior to writing it down. A thematic structure from focus group data emerged using a content analysis. The three themes matched the conceptual domains and these themes guided the generation of the 30-item statements included in the survey. The following sections provide support from the focus groups and the literature for each conceptual domain. 2.1. Countermeasures Workplace violence countermeasures are those resources put in place by the hospital to prevent violent behavior by patients and visitors. The availability and effectiveness of security is one countermeasure that has been identified as a factor in workplace safety [16–18]. Training in handling violent behavior is another countermeasure that has been identified [14,17,19]. Design of the physical environment of the emergency department has also been identified as a possible countermeasure [4]. One of the themes identified by the focus groups of emergency nurses was the availability and abilities of the security officers employed by the hospital. Statements such as, “We need security in the department 24/7,” and “I pushed the panic button but it took security a long time to come,” were common. Benham et al. reported in their survey of academic emergency departments that security was available for most emergency departments but, in general, were not available in patient care areas. When security officers are stationed in the emergency department, incidence of violence decrease [4,14,16]. When security officers did respond, according to focus group participants, they were not always helpful. “I got hand sanitizer thrown in my face and they just stood there and let the guy walk out,” was one example a triage nurse gave about her experience with workplace violence and the security force’s response. “They just stood there while she yelled obscenities at me,” was another response to questions about security’s effectiveness in handling an irate family member. “We never have a problem when Officer ____ is working in the department,” also came up repeatedly. These comments are supported by findings from two qualitative research studies on workplace violence against emer-
C. Burchill / Development of the Personal Workplace Safety Instrument for Emergency Nurses
gency nurses [17,18]. Both studies report that emergency nurses want security officers to control access to the department and have a positive effect with violent patients and visitors. Unfortunately, sometimes the security officers have a negative effect on the situation [18]. Training in de-escalation and personal safety techniques should increase emergency nurses’ perceptions of workplace safety. Training in these techniques, when it is offered by a hospital, is frequently not mandatory for emergency nurses or hospital security officers [4,15,19,20]. Training in these techniques has been shown to decrease the odds of verbal abuse suffered by emergency nurses but not to a statistically significant level [4]. In a large-scale study of workplace violence in emergency departments, Kansagra et al. report that emergency department staff members that received training in violence prevention felt safer than those that had not, though not quite reaching statistical significance in the final analysis [14]. Finally, departmental design has been shown to be a useful countermeasure to workplace violence [4]. Screening for weapons with a metal detector or an xray machine upon entry to the ED waiting room has not been shown to be the most effective countermeasure or increase a sense of safety among the staff [16,17]. Less than half of the emergency departments in a large-scale study of safety measures used by emergency departments are using some form of weapon detection system [16]. Departments that have panic buttons and enclosed nurses stations have been associated with lower rates of verbal abuse by patients and visitors; and, thus, a greater sense of security for emergency nurses [4,14]. Based on the focus group data and the review of the relevant literature, one item was added to rate the perception of the emergency department’s physical plant design for workplace safety. A sample of the instrument items is provided in Table 1. 2.2. Patient-nurse interaction Expectations of patients and their family members of their emergency department experience may be influenced by their subjective state of health, cognitive abilities, and previous experiences and interactions with emergency care providers [21]. The interactions that occur with emergency care providers can greatly influence patient and visitor behavior [4,21]. The idea that patient expectations and interactions may influence a nurse’s perception of personal safety in the emergency department was identified in focus groups.
63
“Patients come here thinking they are the sickest patient, even if they just have a cold,” was one example given by a focus group participant. “I try my best to provide high quality care and excellent customer service in triage but on a really busy night it can be really difficult,” said a nurse referring to her time triaging patients in the waiting room. Some focus group nurses felt that a realistic expectation on the patient’s part and a positive interaction made them feel safer. Interactions with patients and their presenting state have an impact on emergency nurses’ perceptions of their workplace safety [21]. In particular, those patients with psychiatric complaints, who are intoxicated, who present in an emotionally charged state, or who have an impression of poor quality of care in the emergency department can make emergency nurses feel vulnerable to workplace violence [5,17,21,22]. Sample instrument items aimed at examining the relationship between patient-nurse interaction and perception of personal safety are listed in Table 1. 2.3. Hospital and judicial support Workplace violence incidents in emergency departments are dramatically underreported [4,21]. There are many reasons why emergency nurses don’t report workplace violence, including cumbersome reporting systems, lack of response when reported, and reporting it verbally to a supervisor or colleague [4,15]. Research suggests that emergency nurses feel that incident reporting systems are often cumbersome, which decreases chances that emergency nurses will complete the forms [10,24]. User-friendly incident reporting systems are recommended to improve reporting [10,13,23,24]. Another reason that emergency nurses underreport workplace violence is the response, or lack of response, from department and hospital administrators. When emergency nurses do report violence, they are generally dissatisfied with the response from their department or hospital administrator’s actions towards the patient or the investigation into the incident [4,5, 7,8,10,13]. Nurses feel that hospital administrators are the least interested in this problem of all those involved in the problem [5,13]. Emergency nurse focus group participants highlighted some of the factors why they don’t report. “Nothing’s going to change if I report it,” and “I can’t be bothered filling out that long form after an incident. I just want to forget about it,” were comments received from participants. “My manager wanted me to clock
64
C. Burchill / Development of the Personal Workplace Safety Instrument for Emergency Nurses Table 1 Sample of the instrument items
Factor Workplace countermeasures
Instrument item – There are sufficient security officers working in the ED at all times to ensure the safety of coworkers, my patients, their family, and me. – My emergency department has been designed and outfitted to ensure my safety while at work. – Security officers will assist me in trying to manage unacceptable behavior from a patient or family member.
Patient expectations and interactions
– People come to the ED with unrealistic expectations that causes them to act in ways that would be unacceptable in the general public. – Explaining why people are waiting and how the ED system works usually defuses some of the patient or family member aggressiveness. – I feel justified in asking patients and family members to stop using abusive language around me.
Organizational support
– Hospital administration would be more responsive to a threat or violent act committed against a physician than against another member of the health care team. – My physician colleagues will stand behind me when I report violent behavior or threats by a patient or family member. – The judicial system will prosecute to the fullest extent of the law anyone who assaults me.
out before I took the time to fill out the incident report,” said another participant. Some participants also expressed concern with the consequences of filing a police report. One emergency nurse said, “I’ve tried to press charges before and it seemed that the police and district attorney’s office didn’t take it too seriously.” Other participants expressed fear of retaliation from patients, visitors, or hospital administration if they report an incident of workplace violence. Table 1 provides sample items from the instrument related to the factor hospital and judicial support. 2.4. Personal and hospital demographics Certain demographic factors may have a relationship to perception of workplace safety for emergency nurses. Most survey research done on workplace violence against emergency nurses includes some personal, educational, and occupational characteristics. Age of the nurse has been associated with experiencing workplace violence, though with conflicting results. One study found that older age increased the risk for workplace violence [15] while two other studies found that younger age was a risk factor for workplace violence [9,13]. In another study, the researchers reported that more years of experience (tenure) increased the risk for experiencing workplace violence [15]. Gender is reported as a risk factor for experiencing workplace violence. Men are frequently the victims of workplace violence, though the reason for this is unclear especially considering that nursing remains a female dominated profession [8,9,14–16,25]. Racial background has also been studied but the relationship to workplace
violence and safety is unclear [14,15]. Additional demographic characteristics included in the survey but not studied in most research are highest educational level achieved, usual shift worked, employment status, previous experience with workplace violence, and previous experience with workplace violence committed by a co-worker. Determining if participants had training in deescalation and personal safety may have a relationship with feelings of personal safety in the workplace. Training in these techniques has been shown to have a positive effect on workplace violence in some studies [14,25], while another study found no relationship [13]. Previous experience with violence or violent crime not associated with the workplace has also been shown to be a risk factor for experiencing violence in the workplace [15]. This experience may or may not have an impact on perceptions of safety in the workplace but has not been explored in the literature.
3. Validity and pilot testing Using the focus group notes and the literature review as a guide, thirty statements were generated that could be related to emergency nurse perceptions of safety from workplace violence committed by patients and visitors. This would become the Personal Workplace Safety Instrument for Emergency Nurses (PWSI EN). Following the recommendations of content validity experts, three nationally recognized experts, two NIOSH funded researchers on this topic plus a past president of the Emergency Nurses Association, were asked to independently review the statements for clarity and score
C. Burchill / Development of the Personal Workplace Safety Instrument for Emergency Nurses
each statement as either, “not at all relevant,” “somewhat relevant,” “relevant,” or “highly relevant.” A content validity score was calculated by taking the number of experts that rated each statement as, “relevant,” or, “highly relevant” divided by the number of experts. Twenty-nine of thirty statements were rated as, “relevant,” or, “highly relevant.” The cumulative content validity score obtained was 0.98 [26]. The item rated by one expert as, “not at all relevant,” was re-written based on their recommendation. The administrators of an urban, quaternary medical center agreed to allow pilot testing of the instrument. IRB approval was obtained. Seventy-three percent of the full-, part-, and per diem-time emergency nurses volunteered to participate. The participants provided feedback regarding ease of use, relevance, and clarity. Based on feedback, a statement was added to the demographic section that asks participants to rate their fearfulness while at work.
4. Conclusion Much research has been conducted on workplace violence experienced by emergency nurses. Most research examines the frequency, severity, and personal and hospital characteristics associated with workplace violence. Little research exists on those factors that effect emergency nurses’ perceptions of safety from workplace violence committed by patients and visitors. The PWSI EN is a valid instrument to measure nurses’ perceptions of safety in relation to workplace violence Further testing of the instrument is planned prior to a larger study using this instrument. Correlational statistics will be used to determine internal consistency reliability for each item and sub-scale. Construct validity will be determined by factor analysis methods. Descriptive, parametric, and nonparametric statistical analyses will be conducted using the demographic data.
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