Violence and aggression against nurses is a complex occupational hazard facing the nursing profession. Recently, the phenomenon has started receiving a growing national attention. Paradoxically, the job sector with the aim of providing to care for people appears to be at the highest risk of workplace violence. It is difficult to provide an accurate and adequate definition of violence and aggression because the opinion of a person of what constitutes violent behavior varies between cultures and social backgrounds and often the limits between acceptable and unacceptable behavior can be various.
The term “aggression” is referred generally to the behavior that aims to cause harm to another person. On the other hand, with term of “violence” we call – characterize the attack to a person with the intent to cause harm. Violence can be physical or psychological it includes: Threatening behavior (expression of intention to harm, threatening body language, expression of verbal or written threats), Verbal abuse, Humiliation, Destruction of items, Assault (physical violence, use of weapons, rape, murder), Robbery.
Nurses are among the workers in the workforce that many times during their daily duties can become recipients of a violent behaviour. Too frequently, nurses are exposed to violence – primarily from patients, patients’ families, and visitors. “This violence can take the form of intimidation, harassment, stalking, beatings, stabbing, shootings, and other forms of assault”. The consequences from such behaviors can be many; first of all there is a risk of injury. On the other hand, the physiological effects for the nurses that faced a violent incident can result to fear, frustration, lack of trust in hospital administration, and decreased job satisfaction – decreased desire for their own profession. Especially, if the violent incidences take place in the early carrier stages of nurses can even lead them to leave their profession. “Violence not only affects nurses’ perspectives of the profession, but it also undermines recruitment and retention efforts” which is a disadvantage – threaten in the patient’s care effort.
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Problem area
There is considerable evidence that workers in the health care sector are at greater risk of violence than workers in any other sector. The National Nursing council of Greece reveled data which indicate showed that half of all non-fatal injuries from occupational assaults and violent acts occurred in health care and social services settings (ENE, 2011). In addition, they reported that in a annually base, almost 10 in 10,000 employees in the health services sector suffer injuries that require time off from work.
In a national survey conducted in 2008, the results report that in a generally at least 86 per cent of nursing staff has been the recipient of a violent behaviour during their employment. In the same survey, data demonstrate that less than the half of the physical violence incidents against the nurses were reported to the appropriate authorities (Gerberich et al., 2004). This, it happens mainly because of two reasons: a) The nursing staff has inadequate knowledge – information about their rights or they do not trust the national system about the administration of their case regarding the dispensing of justice. b) A big part of the nursing staff has developed the wrong belief that the violent incidents are an expected part of the daily nursing routine that is inevitable. These factors are challenges that should be combated in the nursing profession. The requirements in order to achieve this goal are many; enhance of relevant legislation, administrative support of professionals, improvement of knowledge of nurses about their rights and the appropriate naming of a legally accepted behaviour.
Moreover, the recruitment and retention problem resulting from this violence is especially problematic. According to projections from the Greek Bureau of Labor Statistics, more than 20.000 new nurses will replace currently working register nurses by the next ten years in Greece. (Greek Bureau of Labor Statistics, 2011). This number can be consider as a much more higher if taking into consideration the number of nurses that are going to move in specialties that is less possible to phase a violent behaviour from patient of their family’s members, for instance working in research area. In addition, recent research data indicate that more than the twenty per cent of registered nurses positions are vacant (ENE, 2001). Furthermore, this reduced number of the health care staff poses a risk regarding the receiving of good quality patient care across the Greek National Health care system, which reasonable is going to be decreased (ENE, 2004).
The last years, there have been many efforts to characterize the dimensions – size of the phenomenon of violence against nurses; some of them containing educational seminars of the violence in the workforce or the cultural understanding of health care providers about the violence during the performance of their occupational duties. However, only few of such activities have been tested in a adequate level in order to describe – set their effectiveness or implemented on a wide – scale basis.
Sources of Data and Research
One of the basic challenges in documenting violence that nurses have faced during their occupation is the absence of systematically organized and collected data in the past. Problems with the availability of data include few data sources to determine the magnitude of the problem and variations in definitions, data sources, and methods used in research.
Research Question
What are the nursing staff responses when caring for patients who express violent behaviors within the national health care units in Sparta, Greece?
Aims and objectives – Purpose and specific research issues
The aim of this study is to investigate the effects of a aggressive behaviour from patients to the nursing staff. There will be an effort to meet the following objectives:
1. To report the experiences and responses of nursing staff when caring for patients with who exhibit aggressive behaviors.
2. To identify effective ways in improving the quality of nursing practice in this area.
Research Methodology
Here we focus on the research design and method for the research proposal. The selection of the appropriate research method “is essential in order to achieve the aims and objectives of a study”. Research design, simply can be referred as “a map that explains all the conditions and the data under which the study was performed”. The basic designs used in most of the research studies in order to collect the data and extract the research questions are methods based on qualitative or quantitative analysis. The goal of quantitative research is “to generate research data that can be analyzed using numerical or statistical techniques”. It actually focuses on the size, prevalence, frequency and quantifiable aspects of the analyzed problem (Polit & Beck 2010). However, many researchers believe that the quantitative approach is limited because “it does not address the meaning of life experience in depth that qualitative research can”. On the other hand qualitative approaches are mainly suitable for collection of information with more a subjective approach regarding the examining phenomenon (Burns & Grove 2008). Barbour (2009) suggests that the qualitative method is more adequate in order for studies that are more interested for the effect of a problem on the individuals associated with it. In this project, because of the type of the aims and objectives of the proposed research we have adopted a qualitative approach for analyzing – explaining our final data. By choosing a qualitative method for the data analysis, we will be able to provide a detailed – in depth explanation of the experiences and responses (Burns & Groves 2011) of nursing staff who work with patients who express violent behaviour.
Selection of qualitative descriptive method
The number of approaches exist within qualitative research are various; some of them focusing on cultural – national or sociological effects (Burns & Grove 2011). All these approaches can provide us with valuable results, however in our case another qualitative research approach is selected; this method is called qualitative descriptive approach. The goal of qualitative description is not detailed explanation of the problem in order to conclude in the formation of a sociological explanation of a phenomenon. Here we aim for a straight description phenomenon is desired. This means we are not going to move away from the original data (Sandelowski 2000). This data analysis approach can provide as with the advantage of a direct explanation initially and then understanding of the nursing staff responses – behaviour.
Sample / Population
The term of population can be referred as the total number of elements in which data can be extracted from. A sample is “a subset of a population selected to partake in a study (Polit & Beck 2010) which will be a source of information” (Clifford & Clark 2004). Identification and determination of the population who is more appropriate for our data collection from is the initial step of our research. The sampling source should be appropriate to provide us with adequate related to our research data.
The Qualitative descriptive method is based on the analysis of a large volume of information. For this reason our sample population source is going to be a limited – small number of nursing staff. In this project, we are going to use a sample of 50 participants. We are aware of the limitations of small sampling sizes, however “qualitative research is more concerned with the phenomenon of interest and not the applicability of the findings in other contexts”.
The inclusion and exclusion criteria for participants in the groups will be as follows:
Inclusion Criteria
• Nursing staff that have face a violent incident in the past from a patient or from a member of his/her family.
• More than one year work experience within the nursing field.
Exclusion criteria
• Agency staff working in the health care units at the time of the study.
• Staff with less than one year of work experience.
• Clinical nurse managers (as many times are responsible, directly or indirectly, for the violent behaviour).
Data collection
The data collection method should best suit the aims and objectives of the research. In our case the answers to our main research questions cannot be “closed type” answers. For this reason, we are going to work in a dialogue basis with the participants of the study. This, will provide us the required answers, “open type answers” about the experience and thoughts of nurses faced a violent incident in the past during the performance of their professional duties (Burns & Grove 2011).
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Pilot study – Procedure
When the methodology has been developed, it is advisable to ‘test it out’ before applying it to the actual sample. This procedure of testing it out is done by a means of a pilot study (Welman et al. 2005). According to Burns & Grove (2011) a pilot study is simply a smaller version of the actual study done in preparation of a proposed study. Conducting a pilot study will authenticate the feasibility of conducting a larger scale study. This will help the research team to spot any problems with the research methodology and to refine and develop data collection instruments. For the proposed research a pilot study must be tested upon a smaller sample with a similar design as the actual study (10% of the final). A smaller focus group with only five nursing staff will be conducted by the researcher for the pilot study. The participants of the pilot study will not be permitted to participate in the main study. Depending on the outcomes of the pilot there maybe areas in the research methodology that the researcher may need to be modify.
Data analysis
According to Polit & Beck (2010) data analysis is ‘the systematic organisation and synthesis of research data’. The analysis of data will take place in parallel with a data collection. The researcher intends to utilise qualitative content analysis. This is the ideal method for the analysis of qualitative description (Sandelowski 2000). Hsieh & Shannon (2005) define qualitative content analysis as “a research method for the subjective interpretation of the content of text data through the systematic classification process of coding and identifying themes or patterns”. Inductive and deductive are the two methods of qualitative content analysis. The researcher will use the inductive approach because analysis is derived mostly from raw data. This approach will allow the researcher to immerse themselves in the data to allow new insight to emerge.
Ethical Considerations
Ethical issues are a central part of the research process (Burns & Grove 2011). The principles underlying research are universal and concern issues such as honesty and respect for the rights of individuals in the study (Welman et al. 2005). In Ireland accountability when carrying out nursing research is specified by National Nursing Council (ENE) code of professional conduct for each nurse and midwife which states: In taking part in research, the principles of confidentiality and the provision of appropriate information to enable an informed judgment to be made by the patient must be safeguarded. The nurse has an obligation to ascertain that the research is sanctioned by the appropriate body and to ensure that the rights of the patient are protected at all times. The nurse should be aware of ethical policies and procedures in his/her area of practice.
The right to self determination
This ethical principal is based on respect for a person’s autonomy (Burns & Grove 2011). Participants in the research will be allowed to make a free and informed choice without coercion (Holloway & Wheeler 2002). Potential participants will have the right to ask any questions concerning the study, refuse to give information and withdraw from the study at any stage.
The right to Anonymity and confidentiality
According to Barbour (2008) the need to preserve confidentiality and anonymity is an enshrined principle when undertaking qualitative research. Anonymity refers to the safest way of shielding confidentiality (Polit & Beck 2010). Details such as names of the participants, location and residential care home names will be kept anonymous throughout the study and within the findings. Also we will ensure that identifying information is safely locked away. Passwords will be put in place to ensure that information in the form of computer software/data the data is not accessed by anyone else other than the members of the research team. Setting up these procedures will prevent any accidental breech of confidentiality (Polit & Beck 2010).
Proposed outcome of the study
A report that will outline the research design together with the procedures applied for data collection and analysis will be written up at the end of the research process. A clear explanation of the findings and results will also be written up by the researcher. The researcher anticipates that the findings of the study will provide insight into the responses together with experiences of nursing staff when caring for patients with dementia who exhibit aggressive behaviours in Sparta’s health care units. This will also give the nursing staff an opportunity to reflect on their care for people with dementia who exhibit these challenging behaviours. If the findings of the proposed study are consistent with findings in the literature reviewed, then the following recommendations will be made:
• Increased education and training on aggression mainly focused for nurses in residential care homes.
• More research into the nursing staff role in residential care homes to establish best practice
• The introduction of local and national Policies and procedures regarding reporting and recording incidences of aggression exhibited by people with dementia.
• Set up of support systems for staff who experience aggression in this environment at a local and national level
Limitations
This is the first research study that will be carried out by researcher and this lack of experience may add on to the limitations of the study.
Risks / benefits
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