3.1. Characteristics of the respondents:
15 nurses from different hospitals participated in the study,11 of them were males and 4 were females, the mean age of the respondents was 31.2 years, the minimum 25 years and the maximum 52 years, regarding the educational level of the participants, 11 of them have Bachelor degree in nursing, 2 master’s degree and 2 practical nurses and regarding to the experience in the profession, the mean was 8.7 years, minimum of 2 years, maximum of 27 years.
Some of the study participants mentioned that senior nurses had an experience in handling violence more than new employed nurses.
Also, Study participants mentioned that male nurses are more exposed to violence rather than female nurses due to cultures and norms, RM2P4 mentioned:” Praise be to God, the people here in our country, even if they are not educated, no one is exposed to a female nurse.”
3.2. Presentation of results:
3.2.1. Section one: Factors that cause violence in the ED
By using content data analysis for the interview questions (From your point of view, what are the factors that caused violence in the emergency department?) thirteen causes of violence emerged (subthemes) in the ED from nurses’ perspectives which were grouped into three major themes. Knowledge and attitude related-issues, External-related factors, and System-related issues.
Figure 1, shows the themes and subthemes of factors that cause violence in ED.
The first theme was system-related issues, a variety of these factors which cause violence in the emergency department were highlighted, including: powerless security staff, staff lack of experience and exposure, overcrowded, poor management practices, absence of strict legal policies to deal with violence, long waiting time.
The majority of participants (N=10) talked about the powerlessness of security staff as one of the greatest causes of violence in ED.
RF1P1 said: “We have security personnel, but they are few and their powers less. They can dismantle a conflict, nothing more “
A study conducted by Angland et al. (2014) found that when security staff were presented, violence and aggression were reduced [6]. This also was mentioned by other studies (Gillespie et al. 2012, & Stene, et al. 2015)[7-8].
Also, the majority of nurses (N=10), mentioned that staff lack of experience and exposure to ED tasks and inadequate and inexperienced staff in dealing with violent behaviors represent the most risk factors of violence in ED. Sometimes nurses who are transferred from other departments to cover for the shortage in ED, is an obstacle in performing effective and comprehensive care. The environment and critical nature of ED completely differs from other departments.
SA1P2 said: “I had someone in the emergency room with me, not from the Emergency team, and I did not know how to act frankly. When I asked for help, he came to look at me from behind the curtains and said “OK, what should I do for you!!? “
74% of 81 nurses' participants in a study held in Nigeria by Ogundipe et al. (2012) admitted that they did not receive any type of training on how to handle violent incidents, which negatively affected their experience and exposure to these situations [9].
The poor performance of staff leads to aggressive behavior from patients and their companions.
Nurses are the most important asset of the ED. They should be highly qualified to work in the ED.
MO2P3 explained, “There are some nurses who don’t know how to insert a cannula for a child. Parents come at us hatefully, “We are not experiment fields, do not train on us”
This result was supported by a study conducted by Roche et al. (2014) [10] , that reported the presence of higher skilled nurses with a bachelor of science in nursing degrees were associated with fewer reported perceptions of violence at the ward level.
Moreover, the inappropriate communication and interaction between patients and the health team is also raises the risk of violence.
RM3P2 said: “Unfortunately, sometimes the medical staff do not have good communication techniques such as: "Wait in line.” “There is a patient in line before you.” “What can I do?” “I don't have space.” “Go complain to the Ministry. “
This result is coinciding with a study conducted by Lau et al. (2012) [11] showed that patients' and relatives' tolerance towards waiting times varies and focusing on effective communication may be more appropriate than attempts to reduce waiting times.
Few nurses in this study complained about their colleagues' lack of professional behavior
SH3P6 said: “Joking too much with patients and companions leads to violent behaviour sometimes “
This result is coinciding with the study of Shafran-Tikva et al. (2017) which mentioned that 48% of the respondents stated that staff behavior contributed to violent episodes [12] .
Most of the participants (N=9) spoke about how crowdedness of patients and companions increase the risk of violence in ED which sometimes induced by a lack of places
SN2P3 said: “It is full of patients. I cannot stop my work for a bit, to find an alternative solution for the patient. Not even two minutes of thinking. “
Almost all of the participants agreed that the patient's relatives and escorts perpetrated the violent incidents; in very rare cases, the patients themselves are responsible for the violence, like alcoholic patients and drug abusers.
They also listed the poor management practice as one of the important causes of violence (N=8).
SN2P3 said:” when you know that you have no place for admissions, why not transfer the patient to another hospital. Why should they stay in the emergency department for a day or two? “
MO2P5 said: “In the Emergency Department, in particular, you can’t just assign any nurse there. He\she should be qualified “
According to Seow (2013), ED management entails ensuring that the teams work in an environment (people, system and place) where they can deliver the best care to their patients.
In addition[13].
Some of the nurses complained about the absence of strict legal policies to deal with violence (N=6), which enhances the occurrence of violence.
SH3P2 mentioned: “For those who know no punishment, will misbehave “
This result is supported by Roche et al. (2010), which stated that lack of hospital policy against perpetrators is considered one of the factors that encourage violence [10].
Some of the participants talked about long waiting time, as one of the important causes of violence in ED (N=6)
This result was supported by Crilly et al. (2004) who reported that the average waiting time of patients reported to be perpetrators of violence was 66.2 minute [14] .
All participants highlighted the impact of external-related issues on violence in ED, which was the second theme; they spoke about four types of external related factors, including types of cases, financial problems, political situation, and lack of pre-hospital care qualifications.
The majority of participants confirmed that there is a relationship between types of cases and violence in ED. For example: (street problems, alcohol or drug abusers, political injuries).
These results coincide with the studies of (Pich et al. 2011, Choulau et al. 2012, Stene, et al. 2015) which consider alcoholic patients, patients in pain and stress, as the highest contributing factors that cause violence in ED [15-16-8].
Some of the participants agreed that the financial situation is directly affecting the aggression of patients and their companion and results in violence, some of the patients don't have health insurance, so they have to pay in order to open an emergency medical file and they have to pay for each required medical test, they get angry on the medical staff and start to assault them, this issue may result from poor economic status in Palestine.
This result was supported by Davey et al. (2020) which considered the financial stressors of paying for medical care as one of the factors that cause violence in ED [17].
A few participants mentioned that the political situation in the country lead to violence. Unfortunately, the medical staff is harmed, especially if there are wounded patients in the ED after clashes happened with the occupation soldiers.
MO2P1said: “The emergency medical staff have been attacked by undercover Israeli settlers. They were being beaten with batons and pistols; the base of the pistols was used on the head, back and shoulders. “
This result was explained by Abu Ali (2012) he mentioned that Palestinian face many hardships in their daily lives which leads to a different rate of victims, which will increase frustration aggression process[4]. In addition, this result was supported by the Palestine Red Crescent Society (2010) [18].
A few of the participants identified the lack of pre-hospital care qualifications of emergency medical services staff (EMS), paramedics and referring physicians as causes of violence.
The participants said that most EMS employees are first aiders, their qualifications are very weak, also they do not have effective communication with the patients and most of times they do not coordinate with the emergency departments before referring patients to them.
RF1P4 mentioned: “The ambulance staff does not coordinate with us when they respond to the patients. If they inform us about the traffic accident with four severely injured patients, we would you told them that we have no vacancy; no CT scan; no thoracic surgeon on call... “
The result was supported by Baig et al. (2018) study finding in which the representatives of law enforcement agencies mentioned poor quality of ambulance services and low competency of health care providers as a cause of violence. [19].
The majority of participants talked about people's' knowledge and attitude related-issues, they mentioned peoples' lack of respect as another cause of violence.
RF1P3 said: “The patient told me “Move one of the patients, I want to sit in his place!”
This result was supported by Brophy et al. (2017) who found that lack of respect for healthcare staff is a social risk factor of violence [20].
Also, most of the respondents spoke about misconceptions and socio-cultural beliefs
MM1P3 stated: “The prevailing culture, is that East Jerusalem provides less care for the patients than the Jews“
Albashtawy & Aljezavi (2016), mentioned that the expectation of health care services can be a promoting factor of workplace violence [21].
Some of the respondents mentioned that the lack of people's knowledge of medical procedures leads to misunderstanding and then violence.
MO2P2 stated: “Most people think that when they come to the emergency department this means “I am a high-risk patient, you need to see me now.”
This result supported by Fallahi-Khoshknab et al. (2016) they found that a lack of people’s knowledge of medical staff tasks was the most common contributing factor to physical violence [22]. Moreover, according to Howerton Child & Sussman (2017) the patients may feel frustrated because they are coming to ED and they do not understand the triage process, and the expected time to be seen by a physician [23].
3.2.2. Section two: Staff feelings
By using thematic analysis, four major themes for the interviews emerged relating to the staff feelings. Figure 2. Shows the four themes and sub-themes of staff feelings.
The first theme was feeling helpless and fearful
Fear of personal targeting, fear of bearing the consequences, fear of losing a job and livelihood, SA1P8 noted “I was new, and afraid of losing the contract since we’re still in the training period“
The second theme was feeling overwhelmed, with two subthemes:
Feeling discontent, JM2P1 said: “why is there no one to protect me; why do people think that I get my salary just because they have health insurance. I get very upset, look at the other units, they are exposed to violence much less than in the Emergency Department “
Feeling underappreciated, MM1P1stated: “You feel your knowledge is worthless, I mean, there is no appreciation. As if they are saying … Just treat the patient and finish your work!! “
The third theme was feeling indignity, JS3P1 mentioned: “I felt as if I were a very vile thing, with no value at all. It was a feeling of injustice “
The fourth theme was feeling distressed with two subthemes:
Feeling insecure, HR3P4 stated: “It was a sad feeling. I lost hope. The thing we were not expecting was present “
Feeling upset and provocation, MS3P4 said: “Sometimes, seriously, I go home and cry from the emergency department! I am tired. All of us are mentally strained. “
According to Ramacciati et al. (2015) feeling of injustice, fear and stress may lead to frustration, anxiety, sadness, low self-esteem, and anger that may last for long times and may progress to post-traumatic stress syndrome [24].
According to Hassankhani et al (2018), nurses are suffering from workplace violence consequences; they have mental and physical health risks, threats to professional and social integrity. For example, they suffered from depression, lack of motivation and feeling hopelessness and isolated, feeling of unpleasant emotions like insecurity, sadness, fear, frustration [25].
3.2.3. Section three: Ways of prevention.
The interviewed participants were asked to indicate or to talk about the preventive strategies that might decrease violence against nurses in ED. These strategies are the followings:
- Enhance the security system, all of the participants talked about this point, the importance of security personnel presence around the clock inside the emergency building and increasing the number of security personnel to cover the hospital demands. Also, in hiring process for security personnel hospital managers should take in their consideration to choose those people who are qualified and interested in their work.
- The participants also talked about the importance of activating (code white) which refers to emergency response for a violent person, by creating a special button easy to access in different places in the ED.
- Enhance the quality of care, by applying proper nursing orientation and rotation programs in hospitals, adapting the number of medical staff members to the demand of ED, hiring qualified nurses with effective communication skills, and improving the triage system.
- Enhance the communication process, this includes the communication between pre-hospital care, the ED medical staff, and the hospital medical staff themselves and between the medical staff and patients and their companions. The participants pointed out several important points in this regard, including: demonstrating the ability to face violence by being assertive, trying to control their anger, using body language effectively, talking respectfully, and not arguing with the perpetrators or to react by the same action, and dealing with them according to the situation.
- Do some modifications to the hospital structure by allocating a safety room for the staff and a special entrance for the ambulance and special room next to the ED for non-urgent cases, and a triage room, expanding the hospital to accommodate more cases
- Customer service training, most of the participants agreed with conducting courses in effective communication and how to deal with violence by the Continuous Education Committee in the hospital or including the violence report process in the orientation program for the new employees.
- Create a clear policy for violence by the hospital administrators, include it in the orientation program, and generalize it to all of the employees, also to activate the role of the quality and safety committees in studying and analyzing the incident report in order to find solutions to the problems.
- Regulate the entrance of companion to ED, some of the participants in the study indicated that most of the violent incidents are caused by the companions not by the patients themselves, and the presence of a large number of companions inside the ED without existing of clear instructions which limit their numbers, will leads to overcrowding and chaos.
- Clients’ education, study participants emphasized the importance of raising public awareness, and suggested several methods that could be used, for example: in the waiting room, using a TV screen to display a simple clear video with audio instructions or using large awareness posters or small flyers to display written instructions about the most misunderstood issues in an ED, for example the triage system, or to direct patients with non-urgent cases to visit the out clinics instead of ED. They also emphasized the importance of having a strong role in the media-television and radio, social media, and the Internet, in order to confirm the importance of respecting medical staff and to clarify the laws and consequences of violence on perpetrators.
- Decrease waiting time, it includes shortening the periods of registering, receiving patients to ED, admission to in-patient departments, discharge or transfer processes, also shortening the response time of the ED or consultant physicians.
- Building trust relationship between hospital managers and employees, by making the employees feel safe, and acting professionally in analyzing and addressing problems of violence incident report, in order to encourage employees to report violence, some of the participants talked about the necessity of having females in the administrative structure of the institution, because of cultural issues, sometimes female nurses refrain from reporting the incidence of violence, if they do not find another female employee at the administrative level to discuss the incident with her and talk without restrictions, also some participants suggested that there should be an official lawyer in the institution to defend the legal rights of employees.
4.1. Limitation of the study:
- There are limited researches conducted about violence in ED in Palestine especially the qualitative study. Therefore, it was difficult to compare and discuss the results of the study with local studies.
- The female nurses who are working in ED are fewer than males. Therefore, the interviewed female nurses were minimal in this study. So, the experience, reaction and feelings of female nurses might not be well captured in this study.
- In light of the Corona pandemic, there were many sudden transfers of nurses between departments, which new employees were hired in the emergency department, and most of them did not have enough experience with violence in emergency departments. This led to extending the data collection period.
4.2. Recommendation and implication of the study:
- For the researchers and Palestinian universities:
- To conduct further research related to violence in ED to assess the effect of nurses’ experiences in adopting new strategies and carrying out interventions to reduce work place violence.
- To develop communication, violence and stress management training courses in Palestinian universities.
- For the hospitals and the Palestinian Ministry of Health:
- To implement a violence prevention plan to protect the nurses at the emergency departments and to implement an appropriate and friendly user tool for reporting workplace violence.
- To include the analyzing process of work place violence report in to the job description of the Safety and Quality Committees, and to involve the employees who have been subjected to violence in discussing and analyzing the report in order to determine the risk factors and to find solutions.
- Management in the hospitals should support the employees, maintain their confidentiality and dignity, and do an effective intervention by setting strict laws against workplace violence.
- To hire a proper number of highly qualified nursing staff in the emergency department, cover the staff shortage and apply proper orientation and rotation programs for nurses, in order to increase the quality of services and decrease workplace violence.
- Redesign the ED structure to include waiting areas, triage room, and treatment area, and separate high risk and agitated patients from other patients, in order to organize the department and decrease the overcrowding and unrequired incidents as possible
- Creating a safe environment at work by using suitable precaution, for example: unbreakable glass in the nursing stations, placing non-removable chairs and fixed equipment to prevent them from being thrown on the staff, also to add safety room, security alarm, and emergency exit for the staff to help them in withdrawing from the scene.
- For continuous education departments; to conduct orientation programs for the staff about workplace violence, including the types of violence, reporting system and tools, the importance of reporting process and teach them the ability to evaluate circumstances which lead to violence, and to identify the potential violent patients. Also, to establish a stress management and communication training courses for the ED team.
- To educate and hire special reception personnel with expertise towards high-risk patients, in order to bring them into the ED by the security staff, and also to be a reference to answer the inquiries of patients and their relatives.
- The extensive need for psychological support after violent incidents, which includes referring employees to social workers, rewarding them by hospital management, and giving support from society and the legal system, to decrease burnout and thinking about turnover.
- Develop the security system in ED with clear tasks and responsibilities for the security personnel in order to prevent and respond to incidents appropriately.
4.3. Conclusion:
The results showed that numerous factors can contribute to the prevalence of workplace violence, these factors are classified into three major themes: Knowledge and attitude related-issues, External-related factors and System-related issues, these classifications have thirteen subthemes which are the factors for causing violence in ED. Four major themes from the analysis of the interviews emerged relating to the staff feelings, which are: Feeling overwhelmed, feeling distressed, feeling indignity and feeling helpless and fearful. There is an extensive need for psychological support after violent incidents by hospital managers, society and the legal system.
Moreover, some suggestions were noticed by the participants and researcher, in order to handle violence; universities and hospitals should establish communication, violence and stress management training courses, Moreover, hospitals should restructure the ED by adding triage and waiting times and treatment areas, allocating a safety room, emergency exit and security alarm for the staff and to enhance the security system. In addition, public awareness about the function of ED should be increased.
The results showed that, there is no clear known system of how to report violence. Different issues mentioned by the respondents, prevent ED nurses from reporting violence. One of the most mentioned issues was, mistrust of the hospital, and its ability to get their right, also that they do not want to amplify the problem to become a personal issue.