Table 1 describes background information of all participants. All were female; four were supervisors and 17 were clinical nurses. These respondents served in a range of units: medical wards, surgical wards, psychiatric wards, outpatient clinics, community care centers, recovery rooms, operating rooms, ERs, and intensive care units. On average, they had completed 14 years of service.
Table 1
Basic participants’ information
Participant ID
|
Gender
|
Age
|
Current work unit
|
Position
|
Years in nursing
|
No.1
|
female
|
42
|
Community Care Center
|
Nurse
|
20
|
No.2
|
female
|
36
|
Anesthesiology Department
|
Head nurse
|
12
|
No.3
|
female
|
43
|
Anesthesiology Department/
Postoperative Intensive Care Unit
|
Nurse
|
8
|
No.4
|
female
|
44
|
Emergency Room
|
Nurse
|
11
|
No.5
|
female
|
35
|
Emergency Room
|
Nurse
|
8
|
No.6
|
female
|
39
|
Surgical Ward
|
Nurse
|
14
|
No.7
|
female
|
35
|
Operating Room
|
Nurse
|
15
|
No.8
|
female
|
38
|
Anesthesiology Department/ Postoperative Intensive Care Unit
|
Nurse
|
12
|
No.9
|
female
|
35
|
Outpatient Clinic
|
Nurse
|
6
|
No.10
|
female
|
55
|
Outpatient Clinic
|
Nurse
|
15
|
No.11
|
female
|
42
|
Outpatient Clinic
|
Nurse
|
12
|
No.12
|
female
|
33
|
Emergency Room
|
Nurse
|
13
|
No.13
|
female
|
39
|
Outpatient Clinic
|
Nurse
|
18
|
No.14
|
female
|
39
|
Emergency Room
|
Nurse
|
18
|
No.15
|
female
|
40
|
Anesthesiology Department/
Postoperative Intensive Care Unit
|
Nurse
|
6
|
No.16
|
female
|
44
|
Community Care Center
|
Nurse
|
13
|
No.17
|
female
|
40
|
Medical Ward
|
Nurse
|
15
|
No.18
|
female
|
40
|
Intensive Care Unit
|
Head nurse
|
12
|
No.19
|
female
|
N/A
|
Psychiatry Ward
|
Head nurse
|
35
|
No.20
|
female
|
N/A
|
Nursing Department
|
Nursing Supervisor
|
23
|
No.21
|
female
|
N/A
|
Emergency Room
|
nurse
|
13
|
N/A: unwilling to answer |
【Insert Table 1 about Here】
To identify strategies to prevent or reduce conflict, this study first summarizes one theme of potential violent conflict scenarios and then proposes four themes about the strategies to prevent or de-escalate conflict based on these scenarios.
Theme: Potential violent conflict scenarios
The theme potential violent conflict scenarios comprise four categories as described in Table 2:1. potential for violence resulting from hostile reactions to unreasonable requests from patients/family, 2. caring for patients with mental and behavioral problems, 3. patients waiting a long time for medical consultation, and 4. proximity of physical distance when caring for patients.
1.Potential for violence resulting from hostile reactions to unreasonable requests from patients/family
Hostility towards nurses can arise from denying patients/family unreasonable non-medical care requests like food prep or grooming. For instance, a nurse faced violent conflict after declining such a request.
The “red light for patient needs” is often pressed at night [but it was] the family member [who had] pressed the patient’s red-light button and requested personal housekeeping service. [They said] Oh...he’s sleeping, don’t disturb him, you (nurse) come and cover him or turn off the air conditioner. [No.4]
Respondents noted that patients/families frequently make unreasonable procedural demands during medical care, like asking nurses for immediate explanations of their condition or test results. Failure to meet these needs has led to verbal or physical violence.
In the past week, a family asked about the patient’s condition, but we prefer the doctor to do it. But he felt that the nursing staff’s attitude was not good, so he slammed his hand on the table on the spot. [No.19]
I explained to the patient that this visit was a make-up test and wouldn’t see the report today, then she threatened me saying that she must see the report today no matter what, with a loud roar for at least 5–6 minutes. [No.9]
Respondents also indicated that patients have requested immediate visitation with the doctor after missing their place in the queue, with verbal confrontations arising as a consequence.
Outpatient clinics often have patients who want to jump the queue for a consultation, or the patient number is very far back and argues to be seen first, leading to conflicts between patients and nurses. [No.7]
2. Caring for patients with mental and behavioral problems
Nursing staff confront potential conflict situations when dealing with patients who have mental and behavioral problems (e.g., intoxicated, drug-induced psychosis, psychiatric patients, etc.), especially in the emergency room or psychiatric ward. Patients often verbally threaten caregivers or physically attack caregivers without warning, due to their condition.
We were going to draw his blood, and he suddenly jumped down and ran to the front of the nursing station, and started to speak more and more aggressively, and kept making verbal threats and slapping the table. [No.12]
3. Patients waiting a long time for their medical consultation
Long wait times are occasionally a trigger for emotionally unstable patients to verbally abuse nursing staff. Many respondents pointed out that long wait times at outpatient clinics or emergency care and patients' lack of understanding of administrative procedures are major causes of WPV.
In the obstetrics and gynecology outpatient clinic, the doctor had to leave the clinic to deliver a baby, when a disturbed pregnant woman in the clinic banged on the door and complained loudly for a long time! [No.7]
A patient comes to emergency room for a cold. Although he is in a hurry, we have to deal with emergency first aid immediately. We put him to the back of the line, and he directly threatened to say: I came first, why others than I still come late he can see first. [No.21]
4. Proximity of physical distance when caring for patients
Respondents pointed out that when performing medical tasks that require close physical contact – for example, measuring blood pressure and listening to patients – they often face physical harassment from patients.
I wanted to measure his blood pressure and his hands came up close to me. I pushed away his hands but was very nervous and uncomfortable. [No.21]
A patient physically harassed and attempted to sexually assault a nurse while she was in the psychiatry ward… [No.19]
Table 2
Potential violent conflict scenarios in the medical setting
Theme
|
Category
|
Sub-category
|
Codes (participants’ ID)
|
Potential violent conflict scenarios
|
1.Potential for violence resulting from hostile reactions to unreasonable requests from patients/family
|
Non-medical care requirements
|
Request nurse to make powdered milk (No.1), pull up the blanket for the patient or turn off air conditioning (No.4), change the bed sheets (No.6)
|
Unreasonable medical needs
|
Request nurse to explain the patient’s medical state (No.19), get examination report immediately (No.9), request for immediate hospitalization (No.21, No.5)
|
Make special arrangement
|
Asked to cut the line to see a doctor (No.7, No.9), asked to go ahead to see a doctor (No.7, No.8, No.10, No.11)
|
2.Caring for patients with mental and behavioral problems
|
Care for intoxicated patients
|
Intoxicated patients resisting measurement of vital signs (No.12, No.5), treating wounds (No.20), lying on floor resisting movement (No.5, No.13, No,14), mumbling nonsense (No.21), patient restrained from drinking on ward (No.17)
|
Care for drug-induced psychosis and psychiatric patients
|
Appearing to have drug-induced or psychosis symptoms (No.19, No.12), psychiatric patients with behavioral problems (No.4, No.19, No.2, No.3)
|
3.Patients waiting a long time for medical consultation
|
Long wait times for outpatient clinic
|
Patients waiting impatiently for delayed consultation by doctors (No.7) or for examination (No.11), long wait times at psychiatric outpatient clinic (No.10)
|
Long wait times for emergency care
|
Patients complain of long wait times as they think they are an emergency (No.21, No.5, No.16)
|
4.Proximity of physical distance when caring for patients
|
Nursing staff physically close to the patients
|
Close contact when measuring blood pressure (No.21) or room visit on ward (No.19), proximity to caring for patient in ER (No.14)
|
【Insert Table 2 about Here】
Protective capabilities against potential violence conflict scenarios
Protective capabilities against violence conflict scenarios have been sorted into four themes, as shown in Table 3. Each theme was sub-categorized to prevention or reduction of violent situation responses. The first category is interpersonal communication capabilities which include negotiation, soothing emotions, and empathy. The second category is problem-solving abilities which include distancing oneself from the offender, taking safety precautions, explaining the situation, leaving the room or area, and seeking colleagues’ support. Following is a description of each theme.
Theme1. Protective capabilities to face unreasonable requests from patients
Respondents indicated that when faced with unreasonable requests from patients/families, they often use interpersonal communication skills, including negotiation, being reassuring and seeking support, to prevent or reduce the risk of violence. For example, patients/families often ask nursing staff to perform non-medical care tasks. In this case, to avoid direct refusal and inducing conflict, interviewees indicated that they first explained to the patient the limitations of the nursing staff, then discussed with the families how they can assist with these non-medical care tasks.
I didn’t refuse directly, I told him: there is no such manpower at the moment, so could you help us to help serve your elder. Later when the family member calmed down, I told him: your request is too much, it’s over the medical care. [No.1]
Another situation is when a patient engages in verbal threats and unreasonable demands to see doctors or test reports immediately. The interviewees described how they used communication skills and problem-solving capabilities to avoid a violent incident from a patient:
She threatened me that demanding to see the report immediately no matter what, and she ranted loudly for at least 5–6 minutes. I asked her to go outside and to soothe her emotions a little bit. [No.9]
I’ve often had patients who wanted to jump the queue to see the doctor. One patient’s number was very high but he was arguing to see the doctor first, I would calm him down and then explain to him. [No.7]
Respondents also pointed out situations where they couldn’t satisfy a patient’s family’s requirements to explain the patient’s clinical condition, resulting in a verbal threat or physically aggressive behavior. In this situation, clinical nurses usually asked the supervisor on duty or the physician for support to just walk away.
The first thing you should do is to ask the supervisor on duty to come down to help deal with the situation, but it takes him away from his duties for about 30–40 minutes. [No.5]
Theme 2. Protective skills for caring for patients with mental and behavioral problems
The nursing staff said that the clinical care of alcoholic patients or psychiatric patients required safety actions to prevent violence, such as maintaining a safe distance to avoid close contact or placing hands over the chest to protect themselves. When an alcoholic or psychiatric patient attacks, the nurse can immediately shield or swing away.
Talking to a drunk patient I’m always two steps away from the person, that is, not very close to the patient. [No.20]
I used to put my hand here (in front of my chest) to block or wave it away as soon as he made a sudden movement. [No.14]
Occasionally, direct violence occurs in clinical settings. When physical violence does occur without warning, nursing staff state that they first call the police and then inform their supervisors.
We will avoid some offensive behaviors that we can foresee, however, some situations are unpredictable, and we must call the police first and then notify the supervisor second. [No.5]
Theme 3. Protective capabilities for dealing with patients who have to wait a long time for medical consultation
Nursing staff indicated that when an outpatient has a long wait time, occasionally the patient becomes angry and expressive, even verbally abusive. In this case, they try to placate the patient and discuss alternative options with the outpatient staff (e.g., suggest that the patient be transferred to a second outpatient appointment), and then seek support from the chief nursing officer or supervisor.
I told her that the doctor was delivering a baby and unavailable and offered her to switch to another doctor or something, but she still cursed and cursed and cursed .... I told her I was sorry he had to deliver the baby, but I had to calm her down... Otherwise, please wait for a while...the doctor will return to the clinic after delivering the baby...when there is really no way to deal with the situation, it is necessary to call the head of nursing or supervise. [No.7]
Another situation that occurs in the emergency room relates to the triage process. The interviewees said that non-serious emergency patients would often appear angry and impatient when they had to wait. Nurses listened to the patient’s needs first and then explained to the patient the emergency room procedure and their diagnosis, often reducing the aggressive/ violent behavior.
I spent time listening to the family or patient complaining, and then explain to that because your injury level is about grade 4 or 5, you must wait. Because the patient who is treated first is grade 1, meaning they have immediate life-threatening injuries, so we must help them first. [No.21]
However, if a patient/family member becomes impatient and starts uttering verbal threats or abuse, the interviewees said that they signal to the hospital guard with their eyes, asking him for support or to press the anti-violence alarm linked to the local police station, requesting immediate assistance to help deal with the situation.
If the violent behavior of the other party has affected our medical treatment, we will press the police link and ask the police to help us deal with it. [No.21]
Respondents also indicated that they would leave the scene and stay away from the aggressive patient to avoid more misunderstandings that could anger the patient and produce serious violence, or they would exchange jobs with other nursing staff to avoid further contact with the aggressive patient.
It may be better to leave the scene temporarily and not let the patient become more and more angry. Otherwise, we usually switch to a substitute nurse (often male) and you don’t contact the patient or the family again. [No.5]
Theme 4. Protective skills to cope with close contact patient care
When clinical nursing staff perform routine medical tasks and are in close contact with patients, they usually stay alert. If they perceive any sort of threat, they immediately step back to maintain a safe distance from patients.
When I want to measure his blood pressure, his hand comes up and I step back, so he doesn’t touch me. [No.21]
Respondents also pointed out that when a patient physically harassed and attempted to sexually assault a nursing staff member, they would ask for help from a colleague.
A patient physically harassed and attempted to sexually assault the nurse while she was in the psychiatry ward. Fortunately, the other patient witnessed it and then asked for help from the nursing staff at the nursing station to de-escalate the situation. [No.19]
Table 3
Protective capabilities in violent conflict scenarios
Theme
|
Category
|
Sub-category
|
Codes (participants’ ID)
|
1.Protective capabilities to face unreasonable requests from patients
|
Interpersonal communication skills
|
Negotiation
|
Discussions with family members about what they can do to care for the patient (No.4), asked relatives to help with daily care first, and then told that daily care is not professional care by caregivers (No.1)
|
Soothe emotions
|
Sooth patients’ emotions (No.9), calm patients down (No.7)
|
Problem-solving skills
|
Explain the situation
|
Explain the outpatient process (No.7, No.9)
|
Seek support
|
Ask the supervisor on duty or physician for support (No.5, No.19)
|
2.Protective skills for caring for patients with mental and behavioral problems
|
Interpersonal communication skills
|
Negotiation
|
Negotiate alternatives for patients’ needs (No.19)
|
Problem-solving skills
|
Safe action
|
Stay two steps away from the patients (No. 20), put hands in front of the chest (No. 14), take a step back (No. 19)
|
Seek support
|
Call the police, notify the supervisor (No. 5), call the security guard (No.19, No.2), ask for assistance from other nursing staff (No. 3)
|
3.Protective capabilities for dealing with patients waiting a long time for medical consultation
|
Interpersonal communication skills
|
Negotiation
|
Suggest patients be transferred to a second outpatient appointment (No. 7)
|
Soothe emotions
|
Calm patients down (No. 7)
|
Empathy
|
Listen to the family or patients’ complaints (No. 21)
|
Problem-solving skills
|
Seek support
|
Call the head of nursing (No. 7), signal the hospital guard with eyes for help (No. 21), ask for police assistance (No. 21)
|
Explain the situation
|
Explain the emergency room procedure (No. 21)
|
Leave the scene
|
Leave the aggressive patient temporarily (No.5)
|
4.Protective skills to cope with close contact patient care
|
Problem-solving skills
|
Safe action
|
Take a step back (No.21)
|
Seek support
|
Ask for help from the nursing staff (No.19)
|
【Insert Table 3 about Here】