PhD RPN RGN
Department of Nursing & Midwifery
University of Limerick
Department of Nursing and Health Science
Athlone Institute of Technology
Department of Nursing, Midwifery and Health Studies
Dundalk Institute of Technology
There is certainly growing evidence and international consensus that aggression and violence are real and growing features for those working within health services.(1–3) Aggression and violence are not new phenomena in healthcare environments. Records from as far back as 1889 report on violence and even death among healthcare staff.(4) Despite this, the issue of the exposure of healthcare staff to violence and aggression is one which has not been given adequate attention until relatively recent times. Resistance to acknowledging violence and aggression as problematic features of work settings in healthcare services may be linked with inappropriate concepts of vocation and caring among healthcare professionals.
Understanding aggression and violence directed to healthcare staff
A global view of aggression and violence in healthcare environments is presented in Figure 1. The diagram depicts the multidimensional position of the healthcare practitioner in relation to violence and aggression. He/she is normally cast in the role of healer/helper to those who are in crisis arising from potential or actual violence. This is perhaps the one aspect of the relationship between violence and caring professions that we feel most comfortable with, the caring side of professional life. The other two sides of the triangle are ones that, perhaps, we feel less comfortable with. Historically, healthcare staff have sometimes been perpetrators of violence and aggression. There is ample evidence that systems designed to help individuals through offering places of refuge and asylum sometimes turned into places of violence and oppression. Ireland and many other countries have been rocked in recent years with scandals of institutional abuse that remained hidden for years. This is a topic that needs to be better addressed. Finally, there is the phenomenon of the healthcare professional as a victim of violence and aggression, which will be the subject of this review. Abuse and assaults on staff from service users receives significant attention in professional literature but there is growing evidence that staff-to-patient (vertical)(5) and incidences of staff-to-staff (horizontal) aggression and violence can and do occur.(6)
The scope of the problem
Of all healthcare staff, it appears that nurses experience the most aggression and violence.(2,7–10) Of those, mental health nurses are consistently reported as being the most at risk.(11,12) It has also been noted that, of the total percentage of violent incidents in one hospital, 31% were directed towards nurses, with only 7% directed towards other members of staff.(13) There is long-established evidence of the dangers assumed to be inherent in mental healthcare. When considered in the context of high-risk occupations, one study reported that psychiatric nurses working in public sector facilities in the USA were assumed to be at greater risk of occupational injury, mainly violence.(14)
There is an assumption that mentally ill people are invariably at greater risk of being violent towards other people.(15) A consequence of this thinking is that violence and aggression are seen as “part of the job” for mental health professionals and that staff within those areas become used to abuse and assault. However, mental health service staff are not the only ones at risk. Findings from international studies indicate that staff in many areas such as accident and emergency departments, renal dialysis units and care of the elderly experience high rates of aggression.(16) Healthcare workers are generally ranked as one of the groups most at risk of assault in the UK.(17)
The close link between mental health or illness and violence is also a factor which is seen to influence both recruitment to and attractiveness of mental health nursing.(18) It is well recognised that work environments characterised by aggression and violence are conducive neither to attracting staff nor to retaining them.(19) There is an increasing urgency to examine and address factors which are related to these issues.
While there has been a conscious movement away from reliance on traditional hospital-based services for mental health problems,(20) the association between the experience of aggression or violence and mental health services has persisted in deinstitutionalised services. In one UK study of mental health nurses, 80% of hospital-based nurses and 50% of community-based nurses reported experiences of violence or threat of violence across their careers.(7) This compares with Sweden, where 85% of respondents in one study reported having been exposed to violence in the course of their careers, with 57% reporting having been victimised in the previous year.(21) Indeed, the incidence or prevalence of aggression and violence has been described as being of epidemic proportions.(22,23)
There are clear obligations placed on employers to take appropriate measures to ensure the health and safety of all employees where there is a predictable or reasonably foreseeable risk.(24) Clearly, failure to act from a policy perspective may leave employers open to litigation. However, it would be incorrect to suggest that these are the only motivating factors for employers. Employers value their employees and most are presumably interested in developing preventative and management policies to deal with the risk to staff. There are a number of specific factors that need to be considered in relation to the incidence and prevalence of aggression within mental health settings. One interesting summary of some of these factors suggests that the reduction in specialist mental healthcare personnel who have the skills, knowledge and confidence to successfully manage crises or potential crises is an important contributory factor requiring attention.(25) Implicit in this study is a suggestion that consideration to an appropriate skill mix is needed across all care settings.
While some factors that influence aggression and violence are not unique to mental health settings, there are distinct features within these settings, such as altered cognitions, psychopathology, staff qualities and competencies and environmental cues that need to be considered. In an attempt to capture the complexity of this care setting, some authors(26,27) proposed a model that offers some promise in understanding violence and aggression in mental healthcare. It moves from the conceptualisation of violence as an inevitable symptom or consequence of disorder to a more inclusive understanding.(28) These authors point to the fact that such incidents have complex and differing meanings to the perpetrator and victim.
Definitional issues and reporting
One of the key difficulties persistently identified in the literature has been the precise definition or categorisation of both aggression and violence or what distinguishes them.(10) There is a lack of common understanding among staff as to what constitutes an act of aggression or violence. This may explain consistent under‑reporting and inaccuracies regarding violent and aggressive incidents.(29,30) From a management perspective, underreporting leads to obvious difficulties in terms of making appropriate responses.
The Irish situation
In Ireland, aggression and violence to healthcare staff has been reported as problematic.(17,31) In a study of the experiences of nurses and care assistants in a major general hospital in Dublin, it was found that approximately 50% of both categories of staff experienced physical and verbal assaults and that underreporting was a particular problem.(32)
Contributory factors and categorisations of aggression and violence that present in A&E departments were also identified in an Irish context in another study.(33) The author identified three distinct typologies, namely aggression and violence related to organic causes; psychosocial causes; and environmental factors. In a further study that looked at the experience of aggression and violence in general hospitals it was reported that 15% of respondents had taken time off work at some point because of work-related violence.(34) The same author later identified the extent of the problem of workplace violence in the North Eastern Health Board (NEHB) area.(35) He confirmed a relatively high prevalence of aggression among healthcare personnel, with staff encountering aggression and violence from a range of sources including horizontal aggression and violence, consistent with other national and international studies. This study was extremely important from an Irish perspective as it helped place the issue on the national agenda and identified workplace violence as a problem encountered across a range of employment categories and situations. Additionally, it estimated annual financial costs of up to €304,000 for the former NEHB related to absences directly associated with workplace violence.
There is little doubt that a range of political, social, economic and cultural factors may have influenced the increasing interest in the experience of aggressive and violent incidents among healthcare staff. Despite the increased interest and researcher activity aimed at both understanding and explaining the phenomenon, there appears to be a great diversity of focus and understanding. Much of the literature concentrates on the characteristics of patients that are likely to be violent or aggressive. In that regard, it would appear that the evidence is at the very least inconclusive. While it is undoubtedly important to assess risk and identify individual patient characteristics that are likely to predict violence or aggressive acts, this approach in many ways presumes a sound definitional base of the concepts under consideration. It is not clear that such a presumption may be justifiably made.
It is timely now to concentrate research on:
- Defining the many types of aggression and violence experienced by healthcare staff.
- Developing, testing and implementing risk assessment instruments that will help predict incidents.
- Discovering and addressing factors that inhibit incident reporting to increase reporting accuracy.
- Assessing the extent of horizontal violence among staff.
- Developing evidence-based, pain-free management methods for violent and aggressive service users. Trans-European organisations such as the European Violence in Psychiatry Research Group (EViPRG) and Horatio (the European Association for Psychiatric Nurses) could do much to standardise definitions and interventions across countries. Health services employers need to develop more of a risk management perspective coupled with a “no blame” culture. Staff need to feel a sense of understanding, empathy and support more than being obliged to avail of structured support systems that may be seen more as a form of organisational protection than genuinely supportive in nature.(35) These issues require collaborative approaches to arrive at shared solutions.
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- Annual Report. Dublin: Health & Safety Authority; 2001.
- Wells JSG, et al. Worthy not worthwhile? Choosing careers in caring occupations. Waterford: Centre for Social Care Research, Institute of Technology; 2000.
- Wells JSG, et al. J Psychosoc Nurs Ment Health Serv 2000;7:79-87.
- Ryan D. Community mental healthcare. In: Psychiatric and mental health nursing: the craft of care. London: Arnold Publishers; 2003.
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- McKenna K. Nurses experience of work related assault in Irish general hospitals. Department of Nursing, University College Dublin; 1999.
- McKenna K. Study of work related violence. Report of the North Eastern Health Board Committee on Workplace Violence. North Eastern Health Board, Ireland; 2004.