Nicola Ramacciati

Interventions to reduce the risk of violence toward emergency department staff: current approaches

Introduction The phenomenon of workplace violence in health care settings, and especially in the emergency department (ED), has assumed the dimensions of a real epidemic. Many studies highlight the need for methods to ensure the safety of staff and propose interventions to address the problem. Aim The aim of this review was to propose a narrative of the current approaches to reduce workplace violence in the ED, with a particular focus on evaluating the effectiveness of emergency response programs. Methods A search was conducted between December 1, 2015 and December 7, 2015, in PubMed and CINAHL. Ten intervention studies were selected and analyzed. Results Seven of these interventions were based on sectoral interventions and three on comprehensive actions. Conclusion The studies that have attempted to evaluate the effectiveness of interventions have shown weak evidence to date. Further research is needed to identify effective actions to promote a safe work environment in the ED.

Commentary on Tan MF et al. "Nursing management of aggression in a Singapore emergency department: A qualitative study". Nursing and Health Sciences. 2015; 17: 307-312

We read the recent qualitative study by Mei Fen Tan and colleagues on “Nursing management of aggression in a Singapore emergency department” (Tan et al., 2015) in Nursing&Health Sciences with great interest. Workplace Violence (WPV) in health care is a growing phenomenon worldwide. Many international studies have explored the issue of patient-related violence against nurses, with a particular focus on emergency department (ED) settings (Ramacciati & Ceccagnoli, 2011). These studies are generally analytical and descriptive, based on a mixed qualitative/quantitative methodology (Brunetti & Bambi, 2013). The use of different points of view and different research methodologies, according to a multidimensional analysis and approach (Ramacciati et al., 2013a), can help to better understand this complex and underreported phenomenon. In our opinion, qualitative studies on experiences of nursing staff who are victims of violence is an important research area on WPV in the ED. Certainly, recording the violent incidents (Ferns, 2012) and developing the data-collection instruments (Kowalenko et al., 2012) is essential to identify possible solutions (Ramacciati et al., 2013b). However, qualitative studies can provide interesting interpretations of the problem related to WPV (Catlette, 2005; Luck et al., 2008; Pich et al., 2013; Ramacciati et al., 2014), also with respect to identifying possible interventions and solutions (Gillespie et al., 2013).Many authors are aware, as are we, that a small sample size and restricted geographical area represent a limitation of their qualitative studies, with possible consequences for the general validity of the results. Tan et al. (2015) also noted this limitation. Of course, we too are convinced that many themes highlighted by the research are culturally influenced, but despite the differences, there are many similarities in the experiences of emergency nurses worldwide. The literature findings show analogy in terms of: (i) perceptions/views: violence is seen as an inevitable experience in ED (Pich et al., 2013); administrative support is perceived to be low, whereas perceived peer support is high (Christie, 2014); (ii) feelings, such as anger, fear, sadness, helplessness, and a desire for revenge (Angland et al., 2013), accompanied by anxiety, burnout, depression, and acute and post-traumatic stress disorders are often present (Gillespie et al., 2010). There might be a contributing gender difference; that is, some studies suggest that female nurses are more vulnerable than male staff (Ramacciati et al., 2015); and (iii) contributing factors: often nurses believe that violent behavior can be triggered by the attitude of the nurse (Pich et al., 2011), while tending to justify and play down violent episodes when the violence is seen as triggered by the underlying medical condition, as in psychiatric cases or in alcohol and illicit drug intoxication (Pich et al., 2010). Above all, the emergency nurses do not want to be left without support. It is up to the hospital administration and nursing management to try and tackle this difficult problem. There is, to date, no strong evidence for the efficacy of interventions designed to reduce violence against ED nurses (Anderson et al., 2010), but we must persevere in researching the phenomenon and implementing strategies to overcome this widespread and growing trend.

Workplace violence against nurses in Korea and its impact on professional quality of life and turnover intention.

Dear Editor, We read with interest the paper by Choi and Lee (2017) titled ‘Workplace violence against nurses in Korea and its impact on professional quality of life and turnover intention’ published in the Journal of Nursing Management. We were impressed by the high rates of workplace violence (WPV) (95.5% of the respondents, in a time frame of 12 months) recorded by the authors, indicating the real importance of this phenomenon. Even if the most frequent kind of WPV is verbal abuse, a consistent percentage of respondents reported threatening behaviours (89.9%). We would like to add some considerations emerging from data recorded in Italy. According to our recent national survey about violence towards emergency nurses, which involved 1,093 respondents, accounting for 6.9% of the 15,618 Italian emergency nurses currently in service (Ramacciati, Ceccagnoli, Addey, & Rasero, 2017), the turnover intention and, the desire to leave the profession are significantly related to being a victim of violence, regardless of the type of violence suffered (whether verbal or physical), even if a formal transfer request is not submitted, as shown in Table 1. This is consistent with a previous Italian study (Becattini, Bambi, Palazzi, & Lumini, 2007). Moreover, an issue studied by Choi and Lee is that of horizontal violence (HV), which is a type of abuse perpetrated among nurses. In two recent Italian studies performed with critical care and emergency department nurses the reported rates of HV experienced in the last year were 81.6% (Bambi, Becattini, Pronti, Lumini, & Rasero, 2013) and 79.1% (Bambi et al., 2014), respectively. Actually, we are talking about reports of abuse that are at least single episodes, while the systematic occurrence of this kind of abuse perpetrated by peers (at least once a week for not less than 6 months) is called horizontal bullying (Tomei et al., 2007). Our data reported that 22.4% of nurses working in critical care units, operating rooms, emergency departments and ambulances were bullied by other nurses (Bambi et al., 2014). Interestingly, the bullied nurses made formal requests to leave their units in rates significantly higher than nurses that experienced HV but not in a consistent way (29.3% vs. 6.1%; χ2 = 110.262; p < .0001) (Bambi et al., 2014). At the same time, this group of nurses have more frequently thought to leave definitively the nursing profession (31.2% vs. 7.8%; χ2 = 98.654; p < .0001) (Bambi et al., 2014). Therefore, we think it is important to distinguish the various kinds of WPV (verbal abuse, physical aggression), and to grade the intensity of the abuse to understand the relationship between the violence and its consequences for nurses. We would like to know if the authors found any results similar to ours. Sharing knowledge can help nursing managers find effective solutions to counteract this phenomenon (Ramacciati, Ceccagnoli, Addey, Lumini, & Rasero, 2016). In our opinion, one of the most important elements to solve these problems is a fundamental commitment, starting from nurse executives and managers. Nurses should not be left alone in the face of violence (Ramacciati, Ceccagnoli, & Addey, 2015).

Violence towards emergency nurses: A narrative review of theories and frameworks

INTRODUCTION Workplace Violence in the health environment is a growing issue worldwide. Emergency department have been identified asa high-risk setting for Workplace Violence and emergency nurses are most exposed to this phenomenon. To address workplace violence in the ED effectively, it is critical to understand frameworks established in the literature to assist in development of appropriate interventions and corrective measures. An overview of available theories of violence towards emergency nurses in the literature is presented herein in the format of a narrative review. METHODS A search of international literature on WPV theories was conducted in three databases: PubMed, CINAHL, Scopus, and Proquest Central. Articles concerning theories that have direct implications for patient-related violence (client-on-worker Type 2 Violence) in the emergency department were sought. RESULTS Four hundred and fifty-nine articles were found. Applying established inclusion and exclusion criteria, fourteen of these were included in the review. In the international literature there are 24 theories and frameworks pertaining to violence towards nurses in the emergency department which describe different intervention strategies based on these. DISCUSSION Both the theories on violence developed by nurses and those derived from other disciplines are complex and many key elements are invariably intertwined. Understanding such theories might be useful to manage violence towards emergency nurses with greater effectiveness.

Magnitude of workplace violence in emergency department: another brick in the wall

Dear Editor, Every emergency physician, emergency nurse and ED staff member is aware that there exists a dark side to their ‘fantastic’ job: workplace violence (WPV). This serious problem is unfortunately widespread and afflicts EDs everywhere in the world, no country excluded. Although there are many publications on the problem in the literature, this topic is still understudied. Furthermore, the well-known phenomenon of underreporting hinders researchers in their effort to understand WPV. For this reason, we read with keen interest the paper recently published in Emergency Medicine Australasia entitled ‘Review article: Workplace violence in the emergency department: a systematic review and meta analysis’. Nikathil and colleagues used an interesting procedure to estimate the incidence of WPV in the ED. In this regard, we would like to provide further data. In the ED of Perugia General Hospital (Italy), a third-level ED with 61/70 000 access/year, violent episodes towards emergency nurses have been monitored since May 2010 using a 16item, ad hoc incident reporting form, and adopting the National Institute for Occupational Safety and Health definition of WPV. Table 1 shows the ED attendees, type of violence, perpetrator, incidence of WPV and the proportion of drug and alcohol affected patients among the ED WPV population for the year. Our data places us among the studies analysed by Nikathil, which report low WPV incidence and a variable percentage of drug or alcohol-related violence. Of course, our findings may be related both to the small size of our sample and to the phenomenon of non-reporting; however, to date we have carried out three surveys (April 2013, November 2015 and March 2017) with the nursing staff concerning the reporting of violent events in the past year. In April 2013, 29.6% of the staff reported only ‘some’ episodes, while 62.9% reported none. In November 2015, 17.7% of staff reported some episodes, and 70.6% none. In the last survey (March 2017), we had a significant reduction in underreporting (χ = 0.036, 95% CI): 12.9% of staff reported some episodes, 38.8% none, thanks to the experimental use of a friendly reporting system through smartphone app. For this reason, we are confident that the data presented for the year 2016 on the incidence of WPV in our ED are more realistic. Concerning the precipitating factors present in patientrelated episodes of violence, we may present further data, but in this case, the data are based on the perception of the phenomenon by nurses. We have just finished the ‘Italian National Survey 2016 Violence towards Emergency Nurses’. After contacting 100% of the 670 EDs in Italy, we had 1076 respondents, accounting for 6.9% of the 15 618 Italian emergency nurses currently in service. Item #016 of our validated questionnaire asked for the characteristics of the violent person; Table 2 shows the results. In this case, the percentage of drug (21.11 and 8.72%) and alcohol (32.93%) affected patients in the ED WPV population is much higher. This result is in line with meta-analysis data from Nikathil and colleagues. However, although different models and theoretical frameworks that explain ED violence take into account the biochemical factor (alcohol and drugs) as a fundamental determinant in aggressive patient behaviour of, we are convinced that this is not the only triggering factor. Therefore, it is not enough to be aware early on of the danger situations related to this particular patient condition, but it is necessary to consider all the many factors involved. Focusing only on the biochemical determinants, or related pathological conditions of the patient, which are normally expected, known and

Coping methods used by emergency department nurses after a workplace violence experience could influence their intention to leave the hospital

Commentary on: Jeong IY, et al . The relationship between intention to leave the hospital and coping methods of emergency nurses after workplace violence. J Clin Nurs 2018;27:1692–701. WPV is a widespread phenomenon that is highly prevalent in the health sector, with emergency care nurses among the most exposed groups. Besides understanding and describing the causes of the problem, researchers’ attention has also focused on the consequences of a WPV experience. Several studies have shown a direct correlation between emergency department (ED) …