When people become healthcare practitioners today, perhaps one of the furthest things from their minds is the increasingly violent nature of their potential workplaces. In his article, "Who Cares for Nurses" (2004), though, Cecil Deans makes the point that North American healthcare settings are very violent places to work and many institutions are not providing their practitioners with sufficient protections, and some are simply looking the other way -- all at the expense of the mental and physical well-being of their nursing staff. In their essay, "Challenges Facing Nurses' Associations and Unions: A Global Perspective" (2003), Clark and Clark note that, "Nurses, as the most highly trained caregivers with regular patient contact, are at the heart of any health care system. Widespread anecdotal evidence suggests that the problems in health care have had a particularly negative effect on the workplace experience of nurses" (29). According to Gribbin (2002), "Hospitals can be scary places for patients, but for doctors, nurses and others who work there they can be downright dangerous" (28). Likewise, Hanrahan (1997) points out that: "Nurses get abused all the time. We don't call it that. It's just part of the job" (43). This aspect of being compelled to accept violence in healthcare settings is a common theme in the literature.
The study by Deans points out that violence in the healthcare industry has been widely reported as a serious problem with registered nurses frequently being on the receiving end of physical, verbal and sexual abuse: "Some authors have reported aggression is so prevalent nurses accept it as part of their job" (32). For nurses, the anger that naturally results from being subjected to a hazardous working environment is frequently directed at colleagues and supervisors, with demands for immediate remedies for potentially hazardous work conditions and improvement on existing policies (Clements, Fay-Hillier & Sacks, 2001).
Rationale for Relevance to Nursing/Clinical Practice.
According to Antai-Otong (2001), "Workplace violence is at epidemic levels and grips our society. Workplace murder is the leading cause of death in working women (35% of all female workplace deaths) and the second leading cause of death in working men" (125). Furthermore, the U.S. Bureau of Labor Statistics figures for 1995 showed that 1,071 workers were murdered in the workplace in 1994; the incidence of workplace murders is just one aspect of workplace violence though. "There is growing recognition that all employees face some exposure to violence, by virtue of association with co-workers and client populations. Some data show an estimated 2 million people in the United States are assaulted each year by co-workers and 6.3 million are threatened by co-workers" (Antai-Otong 2001:125). Certainly, violence and assault can take place in any type of work setting regardless of the occupation of the group; however, Chenier (1998) notes that these incidents are rarely isolated, but that there are few employers with preventive programs in place to sufficiently address the needs of their workplace.
The grim reality of violence in many healthcare settings does not mean there are not viable solutions though. According to Boyd, "There may be many situations in which providing staff with both education and in-service training can serve to reduce the risk of violence. Many nurses and health care workers complained that they have little information about the risks posed by specific patients" (492). Many hospitals and other healthcare facilities do not identify, or "flag" patients who are known to be violent, apparently because such an indicator has the potential to bias the caregiver. Nevertheless, Boyd insists that, "A flag is also an educational aid to the caregiver, a technology that, if employed, might result in significant reduction in assaults, with a minimal change in the kind or standard of care provided to the patient" (492). There are also some common-sense approaches to minimizing the potential of violence in healthcare settings: "All concerned know the prescription for dealing with hospital violence: Hospitals have been advised to hire more nurses, beef up the security staff, install metal detectors, control entrances and exits to limit access, keep patients and relatives informed about what's happening and remove from waiting areas all lamps, ashtrays and anything else that can be thrown or used as a weapon" (Gribbin 2002:29). The fact that these precautions are being considered at all is indicative of the current trend toward violence in healthcare settings, a trend that has profound implications for nurses today and in the future.
Problem definition or purpose.
The consequences of violence in the workplace are potentially enormous for nurses today. According to Deans, "The phenomenon of aggression as a stressor has the potential to have extensive detrimental effects on the psychological, social, emotional and physical well-being of nurses. As a consequence nurses may experience lowered levels of concentration at work, and reduction in motivation and performance" (32). Identifying effective means of resolving these issues has assumed enormous importance in recent years, and this is the focus of the study by Deans.
In his study, Who cares for nurses? The lived experience of workplace aggression," the author cites 21 peer-reviewed studies in support of his analysis, with the majority of them being written in the last decade or so; however, the author also resorts to using several resources that are well over 30 years old, and one mental health reference that dates back to 1958; this is not to say, of course, that there is no scholarly merit in these publications; it is to say, though, that a study concerning a contemporary problem should most likely focus on resources that are more up-to-date than the mid-20th century. Otherwise, the literature review provided by Deans in support of his thesis appeared well-rounded and on-point.
In his study, Deans used a convenience sample of 55 registered (Division 1) nurses who had been previously identified as having experienced workplace aggression who consented to be interviewed about their experiences. Out of the original 55 subjects, an additional subset of 33 participants were selected on the basis of their availability; of these, 26 were women and seven were men, ranging in age from 22 to 55 years.
Data collection strategies.
According to Deans, "Participants selected a venue suitable to them in which interviews were conducted, generally in their homes; twelve took place in their work environment. Eighteen participants resided in Melbourne while fifteen resided in rural or regional Victoria" (7) The interviews for the study were recorded and transcribed and generally required between 45 and 80 minutes to complete, with the mean length of 65 minutes (Deans 2004).
Data analysis strategies.
The author used a hybrid analysis of the data by adapting the method described by Colaizzi (1973) and merging it with the interactive model developed by Miles and Huberman (1994). According to Deans, this comprehensive approach provided a superior environment in which to collect the data for this study than either one used independently; the approach involved three primary steps.
The first step in Deans' data analysis strategy involved transcribing the data, listening to audio tapes, returning transcripts to participants and formulating meanings from the transcripts that were returned by participants. The second step required Deans to identify significant words, statements and emerging patterns and common themes. The final step was comprised of a participant check; at this point, the findings were once again returned to participants who were asked to add their own comments about the authenticity of the data. According to Dean, "The validity and reliability of the process was evaluated against four important concepts, namely, homogeneity, inclusiveness, usefulness, clarity and specificity" (33). The author notes that homogeneity was accomplished by ensuring that there was an internal consistency or harmony between the three shared themes in spite of the fact that each theme had separate and independent identities. To this end, the author concludes: "The themes of 'professional incompetency', 'expectation to cope' and 'emotional confusion', were also regarded as having achieved clarity and specificity as they are clear and stated in terms people can understand" (33).
Interpretation of findings, conclusions, recommendations.
There were no earth-shattering revelations in this study, but the author managed to highlight one of the most pressing problems facing healthcare administrators today: "Perhaps the most important implication emanating from this study is that the profession as a whole should become aware of the extent of the problem and the role that nurse colleagues, nurse managers and medical staff play in its genesis" (Deans 2004:35).
The author was sensitive to the traumatic nature of the subject matter under investigation and took appropriate steps to ensure that the ethical issues involved in the study were satisfied. According to Deans, "A considerable period of time was spent at each interview developing a rapport and trust with participants. It was obvious a number of participants continued to have negative experiences as a result of workplace aggression" (Deans 2004:34). A requirement of the University Human Research and Ethics committee that all participants were given the name and telephone number of…