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Nursing and Health Sciences (2015), 17, 307312

Research Article

Nursing management of aggression in a Singapore


emergency department: A qualitative study
Mei Fen Tan, BSc (Nursing) (Hons),1 Violeta Lopez, RN, PhD2 and Michelle Cleary, RN, PhD3
1
Neuroscience Intensive Care, Tan Tock Seng Hospital, 2Alice Lee Centre for Nursing Studies, Yong Loo Lin School of
Medicine, National University of Singapore, Singapore and 3School of Nursing and Midwifery, University of Western
Sydney, Sydney, New South Wales, Australia

Abstract In Singapore, anecdotal evidence suggests that nurses are concerned about managing aggressive incidents in
the emergency department. In this study, registered nurses perceptions of managing aggressive patients in an
emergency department were explored. Ten registered nurses from the emergency department of an acute
public hospital in Singapore were interviewed. Four overarching themes emerged from the thematic analysis:
(i) impact of aggressive patients on nurses; (ii) nursing assessment of aggressive behaviors; (iii) nursing
management of aggressive behaviors; and (iv) organizational support and responsiveness. Further research is
required to better support nurses to deliver optimal care for aggressive patients and achieve positive and
effective outcomes.

Key words aggression, education, emergency department, management, nurse, Singapore.

INTRODUCTION 2010); for example, ED nurses in Taiwan report that restrict-


ing visitors access to ED leads to physical aggression (Tang
Workplace aggression refers to incidents where employees
et al., 2007).While aggression-management training is recom-
are abused, threatened or assaulted or subjected to other
mended for nurses, evidence suggests that the implementa-
offensive behavior in circumstances related to their work
tion of a one-time aggression training program is inadequate,
(Martino, 2003, p. 5). Aggression in the healthcare sector has
and that the content could be more practical (Delaney et al.,
been a concern for many years, especially among the nursing
2001; Pich et al., 2010).
profession. Globally, one-third of the nursing population
In Singapore, the nursing profession is predominantly
experience some form of workplace aggression in any
female, there is a shortage of registered nurses (RN), and the
12 month period, two-thirds of nurses experience non-
nursing workforce has a strong work ethic, typically working
physical violence, and one-quarter experience sexual harass-
long hours to meet tight deadlines (Cleary et al., 2013a,b).
ment (Spector et al., 2014).
According to Gantz et al., (2012), Singapore has a younger
The emergency department (ED) is noted as a high-risk
nursing workforce than in most developed countries, and
area for workplace aggression. For example, in Australia,
there is substantial attrition of nurses within the first three
emergency nurses reported 110 episodes of violence within a
years of their career related to the less-than-ideal working
5 month period, with 37% occurring on the evening shift
environment. Anecdotal evidence suggests there is an
(Crilly et al., 2004). Research shows, ED nurses experienced
absence of policy in support of an aggression-free workplace
physical injuries resulting in psychological effects, such as
(zero-tolerance legislation, prevention strategies, and manda-
anger, burnout, stress, anxiety, and fear (Gillespie & Melby,
tory training in aggression management), which differs to
2003; Needham et al., 2005). Nurses were concerned about
many Western nations (Pich et al., 2010).
their perceived inability to predict patients behaviors and
There is also a paucity of research in relation to patient-
future violent incidents (Canbaz et al., 2008).
related aggression toward nurses, especially in ED. Research
A review of the literature found that a sense of apathy
by Chan et al. (2013) found that patient and/or relative
by nurses or their managers has contributed to the under-
aggression is the most common type of work-related aggres-
reporting of workplace aggression (Pinar & Ucmak, 2010;
sion experienced by healthcare workers. A peer-help,
Wolf et al., 2014). Deficits in administrative and policy-based
multicomponent crisis response-management system has
practices are also noted (Choiniere et al., 2010; Pich et al.,
been made available by the Ministry of Health to Singapore
public general hospitals since 2008, but a multisite healthcare
workers survey by Chan and Chan (2012) revealed that only
Correspondence address: Michelle Cleary, School of Nursing and Midwifery, Univer-
10.6% of nurses have used the system to seek emotional
sity of Western Sydney, Locked Bag 1797, Penrith, NSW 2751, Australia. Email:
m.cleary@uws.edu.au support for work-related aggression. To date, there is only
Received 10 July 2014; revision received 13 October 2014; accepted 31 October 2014 one research study that actually focused on aggression in

2015 Wiley Publishing Asia Pty Ltd. doi: 10.1111/nhs.12188


308 M. F. Tan et al.

Singapore (Yusuf et al., 2006); the restricted scope of the RESULTS


investigation (verbal aggression and psychiatric hospital)
Ten RN aged 2230 years were interviewed, and eight (80%)
limits the applicability of the findings to other general
were female. The participants had spent their entire nursing
hospitals.
career in the ED, and had 28 years of working experience.
ED are a high-risk area for aggression, and abuse toward
Three (30%) participants were diploma holders, four (40%)
nurses is relatively common, accepted as part of the job, and
had an advanced diploma, and three (30%) had attained a
embedded in the culture (Pich et al., 2010). Current evidence
bachelor degree as their highest nursing qualifications at the
points to the need to further explore nurses perspectives of
point of data collection. The thematic analysis yielded four
how best to care for people exhibiting aggressive behaviors,
themes: (i) impact of aggressive patients on nurses; (ii)
which could contribute to efforts in reducing the adverse
nursing assessment of aggressive behaviors; (iii) nursing man-
effect on nurses and identify the impediments for the
agement of aggressive behaviors; and (iv) organizational
required changes by organizations or individual healthcare
support and responsiveness.
professionals (Cohen et al., 2013; Hahn et al., 2012; Needham
et al., 2005; Pich et al., 2010). It is against this background that
the present Singaporean study was developed. In this study, Impact of patients aggressive behaviors on nurses
ED nurses perceptions of managing aggressive patients were
explored. Although there have been a number of studies that ED nurses reported that caring for aggressive people
have focused on the impact of patients aggressive behaviors affected them psychologically and physically. The psychologi-
in nurses, this qualitative study is the first in Singapore to cal effects included feeling upset, not feeling appreciated, and
explore nurses perceptions of managing aggressive patients having recurrent thoughts about what could be done better.
presenting to the ED. The frequent exposure to aggression created job dissatisfac-
tion, resentment, and regrets about initiating the interaction
with the person. Some of the nurses also reported feeling
burned out and wearisome about continuing with their work
METHODS duties:
The setting for this study was a 24 h ED at a major Singapore I was punched . . . it was quite painful. So I kept thinking
general acute hospital, with separate ED facilities for adult what can I do better? Why must I go and attend to that
and pediatric patients. The inclusion criteria were RN who patient? Sometimes I feel like I should just ignore that
had prior contact with aggressive patients and had worked in person. (Participant 3)
the adult ED setting less than three months.
For the protection of human participants, approval for this Fracture was also reported as a consequence of aggression,
study was obtained from the National Healthcare Group and the majority of nurses were not always able to prevent
Domain Specific Review Board. Advertisement flyers and a aggressive incidents. As a result of the physical injuries sus-
staff briefing were used to recruit potential participants. Inter- tained, nurses were not always able to complete their nursing
views were arranged at a mutually-agreed venue and time, duties and were required to take sick leave.
and all participants provided written consent after they all
understood the nature and purpose of the study. The inter-
Nursing assessment of aggressive behaviors
view guide was adapted from a previous study (Delaney
et al., 2001), with permission granted before being piloted An integral part of managing aggression is the ability of
with two colleagues. Interview topics included demographics, nurses to employ various nursing-assessment strategies. In
assessment of aggression, nursing interventions, communica- this study, nurses during their clinical encounter with aggres-
tion skills, education and training, de-escalation and physical sive people used presenting information and previous
restraint skills, post-aggressive incident support and follow history, as well as nurses reflection on past experiences to
up, and other issues or relevant factors. assess the person. They also relied on the medical diagnoses
The interviews were conducted in English and all were (i.e. alcohol intoxication, delirium) to determine the possibil-
digitally recorded, with each lasting between 30 and ity for aggressive behavior. All interviewees indicated that
60 minutes. The principle of data saturation was adopted to alcohol intoxication contributed to a higher likelihood of
establish sample size; that is, until interview content became aggressive behaviors. Nurses also attributed possible under-
repetitive and unlikely to generate new information from lying medical conditions, such as sepsis, electrolyte imbal-
further data collection (Morse & Field, 1996). ances, heat stroke, dementia, and seizures, to aggressive
Data collection and analysis proceeded simultaneously behavior. Several nurses also reported that if they receive
(Coffey & Atkinson, 1996). Verbatim transcriptions of the information on a patient admitted with a drug overdose or a
data were analyzed according to the tenets of thematic analy- risk of self-injury during the handover of care, they would
sis and included becoming familiar with the data, generating consider these patients to be potentially aggressive. Nurses
initial codes, searching for and reviewing themes, defining also used their observation skills as part of the routine assess-
and naming themes, and producing the report (Braun & ment for potentially-aggressive people. Specifically, nurses
Clarke, 2006). These steps provided a systematic process for observed body language, verbal cues, and signs of unhappi-
the researcher to conduct the thematic analysis and develop ness or dissatisfaction via the content, tone, and volume of
themes from the interview data. the patients speech:

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Nursing management of aggression 309

You can observe their behavior is a bit abnormal when a also resorted to seeking help from the security department
patient starts to shout and (they) dont obey your com- when they were unable to satisfactorily manage the aggres-
mands. Potentially, they will be difficult to manage. sive situation:
(Participant 10)
We (nurses] call the security to come . . . You cant pos-
The nurses were quick to determine that those with the sibly sedate an alcohol-intoxicated patient because . . .
aforementioned presentations would have some form of risk they will get more sedated . . . you cant physically
for aggression in addition to being regular users of the ED: restraint them too, because they are . . . (still) conscious
and they are quite strong. (Participant 8)
I already know that this patient tends to be aggressive,
Nurses reported contacting the police if it was perceived to
because they already have a history, or I have already
be a case of severe physical aggression or when the person
seen them being aggressive . . . we have regular patients,
threatened the nurse. Nurses urged for changes so that they
drunk patients, who regularly turn up in our department.
were more supported:
(Participant 9)
I called (the police) to come and help me because it is a
The nurses reported making quick judgements to categorize very violent patient in the department. So after taking
patients, as the use of chemical or physical restraints might be down my report . . . they asked me, Do I want to pursue
necessary to effectively manage aggressive incidents. the matter? . . . I was thinking . . . why am I given a
choice to pursue this matter? Cant they choose to
pursue them instead of me charging him for doing all
Nursing management of aggressive behaviors these violence and vulgarities? Because if I pursue this
Despite sustaining injuries, nurses spoke about their profes- matter, they told me, it is under civil law and I sue him
sional obligations and the importance of upholding standards accordingly. (Participant 7)
and good service. These nurses also reported making extra It was also noteworthy that other than managing aggressive
efforts to interact with aggressive people, even when they incidents, nurses also needed strategies to be able to let go of
were reluctant to do so: negative emotions. Many nurses explained that their coping
strategies had helped, and examples they gave included
You need to . . . be nice to them, but not too nice (to the
venting to colleagues and family, separating professional
extent) you do everything for them . . . just be nice to
duties from ones personal life, and engaging in regular
them, do whatever you need to do. (Participant 1)
leisure activities.
Caring for aggressive people was deemed to be time inten-
sive. As a result, the majority of nurses believed that they Organizational support and responsiveness
could not do what they should do for all persons in their care.
Across all the interviews, nurses adopted a stoic stance on the According to the ED nurses, debriefing sessions conducted
issue of aggression, and viewed dealing with aggressive inci- after incidents were infrequent, and sometimes there were
dents to be part of their job. Nurses perceived that they could none at all. For incidents that were perceived as inconsequen-
manage the challenges of caring for aggressive people, tial, nurses reported that the nurse managers did not show
despite the potential for physical or psychological injury: concern or render support. Inconsequential incidents
appeared to be justified and normalized by the high fre-
Im not affected that much, because I think it (aggres- quency of aggressive incidents. Most of the nurses sought
sion) is normal inside ED, and people come in with these support from colleagues counseling each other to cope
kinds of conditions. (Participant 2) with the emotional effects. They expected front-line leaders,
such as senior nurses, to have the competency to manage
However, some nurses reported instances where they or their
aggressive incidents and to be their role models:
colleagues were unable to maintain professionalism:
I need the help of my senior nurses to teach me . . . how
Of course, at the scene, we are very angry . . . We . . . to properly manage (aggressive patients) or how to
shout at the patient: Hey you dont you must obey decide what interventions to use (in aggression manage-
us. (Participant 3) ment). (Participant 4)
Nurses had proactively offered to take over the responsibility Besides senior nurses, male nurses tend to step forth to assist
for care in the few instances in which they observed their in aggressive incidents. Not all nurses reported being familiar
colleagues being unable to maintain their professionalism with the available guidelines, policies, and procedures that
toward patients. Frequent interaction with patients was could help them manage aggressive incidents. It was sug-
deemed important to prevent aggression, including providing gested that the guidelines should provide a systematic form
information and updates. This included using hospital trans- of assessment to identify people who can potentially turn
lators if language was deemed a communication barrier. aggressive. However, current guidelines, protocols, and poli-
Chemical and physical restraints were used to manage cies provided directions on when to call the police and seek
aggression to ensure safety and allow the healthcare staff to help. It appears that most nurses filed police reports when
carry out important investigations and treatments. Nurses they received verbal threats from their patients:

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310 M. F. Tan et al.

One patient said: You dont let me see you outside the economic reasons, could also result in patients exhibiting
hospital. Ill kill you if I see you. So because of this case, aggressive behaviors. Previous research has reported similar
we made a police report. Because it is (a) threat and you findings, where nurses perceived that people who could not
wont know if he really will come back and kill you, tolerate the long waiting times were potential aggressors
because he can just wait outside for you in (this hospi- (Wong et al., 2007; Wolf et al., 2014). This problem is also
tal), then . . . follow you home. (Participant 6) attributed to the current setting in this study, where waiting
times to see a doctor could vary between 4 and 10 h. Strate-
As part of the EDs protocol, it was mandatory for nurses to
gies to decrease waiting times are currently being reviewed in
write incident reports for incidents of physical aggression.
this setting.
Similar to incidents of verbal aggression, nurses reported that
In this study, nurses also depended on the recall of past
the decision to complete a report was at their discretion.
experiences to identify potential aggressors. These were
Across all interviews, nurses believed that incident reports
people whom they have had previous aggressive encounters
were important and necessary to avert legal liabilities in the
with. Observation skills were particularly useful for nurses in
event of alleged negligence or complaints against the nurse:
this study in identifying behavioral cues for potential aggres-
Because the patient is threatening us . . . we really have sors. It might be useful if ED nurses in Singapore consider
to do write something in the incident report . . . if ever formal assessment tools to guide their assessment for aggres-
the patient sues us or writes a complaint letter, we have sion risk, and this warrants further consideration.
this written report of what really happened that time, Nurses in this study perceived the care of aggressive
that day. (Participant 5) people as part of their everyday work duties; this was justified
by the common occurrence of aggression in their workplace.
Despite the importance of incident reporting, nurses found
The challenge for ED nurses was maintaining their profes-
the process cumbersome. They also perceived that manage-
sionalism during an aggressive encounter. As part of their
ment rarely acted on reports or provided additional
professional code, nurses are required to embody core values
resources to support nurses in managing aggressive incidents.
of care and empathy, although it might prove difficult to
Workplace education, preparation, and training were
express naturally in non-ideal situations (Zapf, 2002; Spector
deemed important to prepare nurses in ED for their role in
et al., 2014), especially when dealing with people who might
managing aggressive behaviors. Some nurses stressed the
not be appreciative of the nurses efforts.
importance of actual workplace experience in gaining skills,
Nurses urged for the development of resources in order to
knowledge, and confidence:
help them cope with the challenges in the workplace, and
I think the experience gained from working here will they valued security and police as aggression-management
help you . . . It is better than any course . . . there is no resources. Similar to previous studies, nurses reported that
course that can teach you. It is just valuable experience. most of the security guards were quick in their arrival and
(Participant 6) assisted the nurses during aggressive incidents (Gillespie
et al., 2012). However, more organizational efforts are
needed in ensuring a reliable security workforce that can
DISCUSSION
readily assist in aggressive incidents.
ED nurses experiences of the impact of patients aggression, As demonstrated in the findings, nurses acquired
as well as their perceptions of managing aggressive patients, aggression-management skills by learning from other more
were explored in this study.The findings resonated with many experienced nurses when transitioning to the workplace as
other studies about the myriad of consequences ED nurses graduate nurses. The benefits of role modeling are noted in
experience from aggressive encounters (Gillespie & Melby, the literature (Omansky, 2010; Cleary et al., 2013). Nurses
2003; Zampieron et al., 2010). Nurses in this study reported recommended aggression-management training programs to
bodily injuries (e.g. being hit, kicked, and pushed), and ver- enhance their confidence, as well as the need to strengthen
balized reluctance in caring for aggressive people, although current induction programs. Most of the nurses mentioned
acknowledging their professional obligation to care for such the use of current guidelines, protocols, and policies in
people.The findings regarding these negative effects resonate guiding their nursing care of aggressive patients in this study.
with the literature, including feeling burned out (Gillespie & However, they expressed a need for further organization
Melby, 2003; Lau et al., 2012; Lo et al., 2012; Chan et al., 2013; support to enhance the available support and network system
Kowalenko et al., 2013). for staff who encounter or work with aggressive patients,
The nurses were able to identify potentially-aggressive including the provision of a formal debriefing system.
people when they factored the patients medical or non-
medical presentation into account. The findings of this study
Study limitations
are supported by previous research. Alcohol intoxication, the
use of drugs/drug overdose, as well as the presence of mental As with all studies, there are a number of limitations for this
illness were cited by nurses as contributing to aggressive research project. The project was conducted at a single site
incidents (Crilly et al., 2004). Similarly, nurses cited medical with a small group of ED nurses. Further, findings explored
conditions as biomedical cues to determine the aggression registered nurses experiences in one emergency department
risk of patients. Health service-related reasons, such as long in Singapore, and therefore, are restricted in scope and trans-
waiting times or patients seeking ED admission due to socio- ferability, especially in Western countries.

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Nursing management of aggression 311

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