Burnout, Stress, Violence and Aggression in Emergency Care

Introduction

Emergency care settings are physically- and emotionally-demanding environments, both for the nurses who work within them and for the patients who present there for care. Burnout and stress, and violence and aggression, are problems which are commonly encountered by nurses working in emergency care settings in the United Kingdom (UK). This chapter discusses burnout and stress, and violence and aggression, in emergency care settings, beginning with an overview of the reasons why these issues occur and how they can be recognised. The chapter goes on to present a variety of strategies and techniques that nurses working in emergency care settings can implement to effectively manage burnout and stress, and violence and aggression.

Burnout and stress in the emergency care setting

Burnout and stress are significant problems for nurses working in all clinical settings; indeed, stress is the single largest cause of sickness absence among nurses in the UK. Research conducted by the Royal College of Nursing (2013) suggests that the majority of National Hospital Service (NHS) staff experience some degree of work-related stress. Because of the intensity of the emergency care setting, it is likely that nurses working in this setting experience a higher degree of stress than those working in other settings.

Research conducted by the Royal College of Nursing (2013) suggests that there are 10 key reasons why nurses in the UK experience work-related stress:

Workload. Staff shortages. Lack of time to complete tasks. Lack of adequate rest breaks. Poor management.

Requirement to work long hours. Lack of control over working environment. Worries about job security. Worries about finances / income. Poor organisational policies.

However, there may be a variety of other issues which underpin nurses' experience of work-related stress. These issues include issues associated with understaffing, lack of clarity with job roles (including a requirement to work beyond scope), lack of proactive management support, dysfunctional working relationships, organisational change, the need to meet targets, patient demands, lack of a work-life balance, and bullying / harassment, etc. The experience of aggression and violence, which you will study in greater detail in a later section of this chapter, is another significant source of stress for nurses generally, and particularly for those working in emergency care settings.

Where stress is significant, and where it occurs over long periods, stress may lead to burnout. Burnout is a feeling of acute exhaustion, which may result in both physical and / or psychological illness. It is particularly seen in professions such as nursing, which involve caring work and where people are regularly exposed to human suffering and are expected to 'give a part of themselves' in completing their work. The Royal College of Nursing (2013) suggests that 42% of nurses in the UK consider themselves to be 'burned out'; this is the highest rate of work-related burnout among nurses of any European nation. It is important to note that burnout usually occurs gradually and covertly; nurses may struggle to continue in their stressful role for some time, before something (often a situation in the clinical setting) causes them to realise that they are simply unable to continue.

Stress and burnout can have a number of significant negative consequences, both for nurses and for the patients for whom they care. Importantly, it can lead to nurses disengaging from their work in an effort to cope with the stresses it brings, and subsequently depersonalising patients (a situation known as 'compassion fatigue'). This can result in a number of poor outcomes for patients, essentially because it increases the risk of poor-quality care delivery. Burnout leads to an increase in presenteeism (i.e. where nurses present to work even if they are unwell and unfit), an increase in the need for sickness absence, and also plays a crucial role in nurses' decision to leave the emergency care setting - or even the nursing profession more broadly. It may also contribute to the incidence of aggression and violence in emergency care settings, through mechanisms you will study in greater detail in a later section of this unit.

Managing burnout and stress

The first step for nurses in managing their stress and / or burnout is to identify that these are problems they may be experiencing. There are a number of different checklist-type tools which a nurse working in an emergency care setting can use to determine their risk and / or level of burnout. Generally, these tools ask about the nature of the organisation in which nurses work, about the interdisciplinary team in which they work, about the self-care strategies they use (if any), and about the presence of any physical / psychological indicators of stress and / or burnout. You are encouraged to explore the variety of assessment tools for stress and / or burnout available for nurses to access online. Generally, nurses who experience stress and / or burnout:

• Are fatigued and / or frustrated most of the time.
• Are often sick with minor illness (e.g. with colds, headaches, muscle pain, etc.).
• Record a change in their appetite, weight and / or sleep patterns.
• Are anxious and / or depressed, and may show signs of clinical mental illness.
• Feel failure, self-doubt, detachment, loss of motivation, lack of satisfaction, etc.
• Lack satisfaction and a sense of accomplishment in relation to their work.
• May withdraw from their responsibilities, procrastinate and / or disengage from work.
• Use food and / or alcohol or other drugs to cope with their stress.
• Report a lack of control, lack of recognition, excessive demands, or extreme pressure.

As highlighted in the previous section of this chapter, burnout and stress are often underpinned by work-related issues at the organisational level, over which nurses may have little control (e.g. excessive workloads, staff shortages, lack of time to complete tasks, lack of adequate rest breaks, poor management, etc.). However, there are a number of self-care strategies that nurses working in emergency care settings may implement to enable them to respond in a more positive way to these challenges - therefore allowing them to prevent and / or manage their experience of work-related stress and / or burnout more effectively. Consider the following list:

• Ensuring adequate rest, including breaks at work and a good night's sleep.
• Eating a healthy, well-balanced diet, including when at work.
• Engaging in adequate exercise; this is one of the most effective natural stress-relievers.
• Using relaxation strategies (e.g. meditation, or participation in a hobby, etc.).
• Talking with others, both at work and outside it, about work-related problems.
• Ensuring that work does not interfere with personal time (i.e. 'leave work at work').
• Being aware of personal scope and limits, and working within these.
• Raising issues with managers as they occur, and actively contributing to solutions.

It is important to highlight that many emergency care settings in the UK offer nurses tools and training they can use to prevent and / or manage their experience of work-related stress and / or burnout.

Violence and aggression in the emergency care setting

In addition to stress and burnout, described in the previous sections of this chapter, violence and aggression are also significant problems in emergency care settings in the UK. Each day, NHS staff in the UK experience more than 150 incidents of violence and aggression, with most occurring in 'high-pressure' areas such as Accident and Emergency (A&E) Departments. There are more than 55000 physical assaults reported against NHS staff in the UK each year, including 30200 physical assaults in emergency care settings specifically, and incidents of verbal assault are significantly more common. As stated by the Design Council (2011: p. 15), "the NHS Constitution pledges a safe working environment for the NHS workforce, but it is clear that solutions are needed to help make this a reality for frontline staff".

It is important for nurses working in emergency care settings to be able to distinguish between violence (including physical vs. non-physical violence) and aggression. Read the following:

The NHS distinguishes between physical and non-physical violence. Physical violence is defined by NHS Protect as "the intentional application of force to the person of another, without lawful justification, resulting in physical injury or personal discomfort". Non-physical violence is "the use of inappropriate words or behaviour causing distress and/or constituting harassment".

A commonly used definition of aggressive behaviour in a healthcare context is: "Any form of behaviour directed toward the goal of harming or injuring another living being who is motivated to avoid such treatment".

(Adapted from Design Council, 2011)

There are a number of common features of 'violent' and 'aggressive' acts perpetrated in emergency care settings in the UK:

• They are interactions which occur between two or more people.
• They involve the use of force against a person and / or property.
• They involve verbal and / or physical aspects.
• They result in both short- and long-term physical and / or emotional consequences.

It is important to understand that violence and aggression in emergency care settings in the UK occurs on a scale of severity. The scale presented following ranks violent and aggressive acts in order of increasing severity:

Moderate verbal hostility; inappropriate use of language, etc.

Significant verbal hostility; offensive use of language; profanity, etc.

Physical contact; damage to property, etc.

Physical violence resulting in minor injury.

Physical violence resulting in moderate or serious injury.

It is estimated that violence and aggression costs the NHS £69 million each year. Many hospitals in the UK now employ security personnel in emergency care settings, particularly on weekends, to protect staff. Violence and aggression in health care settings has significant effects on individual staff and service users, impacting them both physically and psychologically in a variety of complex, negative ways. The time taken for staff to recover from incidents of violence and aggression places a greater strain on already overstretched emergency care settings, and staff morale and productivity are also affected. Following an experience of violence and aggression, a significant number of NHS nurses choose to leave the emergency care setting - or even the nursing profession more broadly.

The Design Council (2011) suggests that people who perpetrate violence and aggression in health care settings in the UK are usually those who are:

• Clinically confused (e.g. due to hypoxia, neurological injury, dementia, etc.). The violent / aggressive acts perpetrated by these patients are usually directed towards clinicians but generally lack intent, as the person is not in control of their behaviour.
• Frustrated, often because they are required to wait to receive care. Frustration may build gradually over time, or it may occur with no obvious advanced warning.
• Intoxicated (e.g. with alcohol and / or other drugs). Alcohol and other drugs impair a person's cognitive function, judgement and ability to predict consequences, etc.
• Anti-social / angry, with a history or pattern of violent and / or aggressive behaviour.
• Distressed / frightened (e.g. due to their experience in the emergency care setting, or because of the event which bought them to this setting, etc.).
• Socially isolated. Because many emergency care settings are open continuously 24 hours per day, 7 days per week, they can "become a strange gathering place for all sorts of people who are lonely or have nowhere else to go" (Design Council, 2011: p. 50). These people may be threatening and manipulative towards staff.

The Design Council (2011) also reports on a number of triggers for violence and aggression in health care settings in the UK:

• Clash of people: emergency care settings are crowded with a variety of different people who are forced together in a high-pressure setting; each of these people are experiencing their own difficult circumstances and have their own needs.
• Lack of progression: some people become frustrated when they are required to wait any length of time to receive care, particularly when they consider the experience uncomfortable and boring. Many people perceive emergency staff to be disorganised, inefficient, and lacking focus (although this is generally not the case). Patients who are required to queue for long periods may feel 'forgotten' or 'unimportant'.
• Inhospitable environment: hospitals generally, and high-pressure emergency care settings in particular, are not pleasant places in which to spend time. Some people perceive emergency care settings in particular to be 'dehumanising', particularly if they are poorly maintained and / or 'dirty', and there is no option for sustenance.
• Intense emotions: people in emergency care settings are often experiencing significant negative life events and suffering with pain and / or stress, all while observing those around them go through the same complex situations and emotions. People may be stressed due to the trauma they experienced prior to their emergency visit, about difficulties with parking, about the complex patient processing system, and / or about how to get home after treatment, etc. Service users tend to pick up on, reflect and, perhaps, magnify each others' stress.
• Unsafe environment: many people perceive emergency care settings to be unsafe environments - because they are crowded, because there are many people who are considerably unwell, because they often result in a loss of patient dignity, and because there is a large amount of equipment in use, etc.
• Inconsistent response: many patients may fail to understand the triage process, and wonder why they are left waiting for care when those arriving later are seen urgently. Additionally, on occasion staff attempt to placate patients who are violent and aggressive with 'special treatment', which can frustrate others in the setting.
• Staff fatigue: emergency care settings are physically- and emotionally-demanding environments, and staff may struggle to manage the constant flow of patients. Research suggests that staff working in emergency care settings often perceive the general public to be 'rude' and 'demanding'. Unpredictable workloads, critically unwell patients and a high-pressure work environment can all contribute to negative attitudes and lack of patience among staff in emergency care settings.

Managing violence and aggression

There are a variety of strategies employed in emergency care settings in the UK to prevent and control violence and aggression. Read the following example:

120,000 patients each year visit Birmingham Heartlands Hospital's Emergency Department. Prior to implementing prevention and control strategies, it recorded 24 incidents of violence and aggression towards staff per month. With a £500,000 government grant, design changes were implemented that reduced the incidence of violence and aggression by more than half (there are currently fewer than 10 reported incidents per month):

• Better signage has been installed.
• A new reception area includes transparent safety screens that can be controlled by staff.
• New chairs, air conditioning, and drink machines and a pay phone were installed in the waiting area to reduce stress levels of visitors.

(Adapted from Design Council, 2011)

There are also strategies that nurses working in emergency care settings can use to manage violence and aggression. Essentially:

• For lower-level aggression, the aim is to prevent progression to violence. This involves responding early to the triggers of aggression and violence described earlier in this chapter. Nurses can achieve this through their interactions with patients and their family / carers at all stages of their visit to the emergency care setting.

Research suggests that it is important for staff working in emergency care settings to manage people's expectations and reduce their anxiety. This can be achieved by communicating to patients and their family / carers: (1) how the patient processing system in emergency care settings works, particularly in terms of triage, and (2) what will happen to the patient during their time in the emergency care setting. Nurses may provide patients and their families / carers with accurate information about:

• How busy the emergency care setting currently is, including expected wait times.
• Why they are waiting, what they are waiting for and what will happen next. 
• Options and alternatives to emergency care service provision (if appropriate).
• Where they should go and what they should do at different stages of their visit.
• Who to seek assistance and information from, and how to do so.
• Expected outcomes of their visit to the emergency care setting (if appropriate).

It is important that nurses working in emergency care settings consider information governance - that is, how they share information with patients and their families / carers. You studied the legal and ethical issues associated with privacy and confidentiality in the emergency care setting in an earlier chapter of this module; you should revise this section now, if required. At all times, nurses must provide information to patients and their families / carers within the bounds of their legal, ethical and professional responsibilities related to privacy and confidentiality. If they are unable to share particular information with patients and their families / carers, it is important to give a frank explanation as to why this is the case. Consider the following example:

In dealing with violence and aggression in the emergency care setting, it is also important to make a note about the presence of family / carers during life-saving procedures, such as resuscitation. Occasionally, family / carers will witness somebody they care about enter cardiac and / or respiratory failure in an emergency care setting, and they may observe clinical staff administer aggressive interventions such as cardiopulmonary resuscitation (CPR) - which may or may not be successful in saving the patient's life. These situations are among the most stressful that people in emergency care settings will encounter - they are, therefore, likely to bring about aggressive and / or violent behaviour. In these situations, it is important that a dedicated nurse attends the family member/s or carer/s to explain what is happening and why, to ensure family / carers do not impede the resuscitation efforts, and to support family / carers to leave the setting if they choose to do so. Regardless of the outcome of the resuscitation, it can be traumatic to witness; family member/s or carer/s should therefore be provided with appropriate support after resuscitation (e.g. opportunities for debrief and counselling, etc.).

Nurses working in emergency care settings must follow their organisation's policies and procedures in terms of reporting low-level aggression. Research from the Design Council (2011) suggests that up to 50% of incidents of low-level aggression, particularly verbal abuse, which occur in emergency care settings go unreported. If these situations are unreported, they cannot be adequately managed; furthermore, the scale of the problem is unclear to the decision-makers with the authority to guide the allocation of funding and the implementation of strategies to manage violence / aggression in emergency care settings.

• For higher-level aggression or violence, the aim is to contain and defend oneself.

There are a number of strategies that nurses working in emergency care settings may use to contain and / or defend themselves from aggression or violence. De-escalation techniques should be used, where appropriate; these techniques are used with the intention of calming an angry person, and they may include techniques such as:

• Physical behaviours: allowing the person physical space, avoiding constant eye contact, standing at an angle to the person, keeping hands free for defence, etc.
• Verbal behaviours: maintaining a calm tone, not responding to provocative questions / statements, explaining limits and rules, empathising, avoiding judgement, etc.

Consider the following example:

It is important to note that many health care settings in the UK offer nurses the opportunity to participate in de-escalation training.

Containing and / or defending oneself from aggression or violence often involves liaising with security personnel and / or police officers present in the emergency care setting. It is important that nurses work closely with these professionals to: (1) identify patients who are, or who have the potential to become, violent and / or aggressive, and (2) effectively manage these patients. This may involve forms of seclusion and / or restraint of people (usually patients) within the emergency care setting; it is important to note that there are a variety of legal, ethical and professional responsibilities related to the use of seclusion and restraint in health care settings in the UK, and it is essential that nurses working in emergency care settings are familiar with, and work within the bounds of, these. It may also involve the removal of a person from the emergency care setting if they continue to behave inappropriately. 

Consider the following example:

Conclusion

Emergency care settings are physically- and emotionally-demanding environments - both for the nurses who work within them and for the patients who present there for care. Burnout and stress, and violence and aggression, are problems which are commonly encountered by nurses working in emergency care settings in the UK. This chapter has discussed burnout and stress, and violence and aggression, in emergency care settings, beginning with an overview of the reasons why these issues occur and how they can be recognised. The chapter also presents a variety of strategies and techniques that nurses working in emergency care settings can implement to effectively manage burnout and stress, and violence and aggression.

This chapter concludes this module. In this module, you have been introduced to the challenging, but ultimately diverse and exciting, field of emergency nursing. You have learned how to triage, rapidly assess and resuscitate a patient in the emergency care setting. You have learned how to identify, assess and manage a variety of traumatic injuries (including those affecting the head, neurological, orthopaedic, spinal, thoracic, abdominal, genitourinary and maxillofacial regions) and medical illnesses (including those affecting the respiratory, cardiovascular, neurological, gastrointestinal, genitourinary / renal and endocrine systems, and those involving substance intoxication). You have learned how identify, assess and manage a number of different types of burns and shock, and how to effectively manage different types of pain in the emergency care setting. Finally, in this chapter, you have studied how to identify and manage burnout and stress, and violence and aggression, in emergency care settings. This module has provided you with the fundamental knowledge you require to provide high-quality nursing care to patients in emergency care settings.

Reference list

Design Council. (2011). Reducing Violence and Aggression in A&E Through a Better Experience. Retrieved from: https://www.designcouncil.org.uk/sites/default/files/asset/document/ReducingViolenceAndAggressionInAandE.pdf

Howard, P.K. & Steinmann, R.A. (Eds.). (2010). Sheehy's Emergency Nursing: Principles and Practice. Naperville, IL: Mosby Elsevier.

Jones, G., Endacott, R. & Crouch, R. (2007). Emergency Nursing Care: Principles and Practice. Cambridge: Cambridge University Press.

Royal College of Nursing. (2005). Burnout: A Spiritual Crisis. Retrieved from: http://journals.rcni.com/userimages/ContentEditor/1373365517540/Burnout-a-spiritual-crisis.pdf

Royal College of Nursing. (2013). Beyond Breaking Point. Retrieved from: https://www2.rcn.org.uk/__data/assets/pdf_file/0005/541778/004448.pdf