Aggression in Healthcare - AbsoluteAstronomy.com

Aggression

In psychology, as well as other social and behavioral sciences, aggression refers to behavior between members of the same species that is intended to cause humiliation, pain, or harm. Ferguson and Beaver defined aggressive behavior as "Behavior which is intended to increase the social dominance of...

was, in 1968, described by Moyer as “a behaviour that causes or leads to harm, damage or destruction of another organism”. Human aggression has more recently been defined as “any behaviour directed toward another individual that is carried out with the proximate intent to cause harm”.

The definition can be extended to include the fact that aggression can be physical, verbal, active or passive and be directly or indirectly focussed at the victim–with or without the use of a weapon

Weapon

A weapon, arm, or armament is a tool or instrument used with the aim of causing damage or harm to living beings or artificial structures or systems...

, and possibly incorporating psychological or emotional tactics. It requires the perpetrator to have intent, and the victim to attempt evasion of the actions. Hence harm that is accidental cannot be considered aggressive as it does not incorporate intent, nor can harm implicated with intent to help (for example the pain experienced by a patient during dental treatment) be classed as aggression as there is no motivation to evade the action. A description of workplace violence

Workplace violence

Workplace violence refers to violence that originates from employees or employers and threatens employers and/or other employees.-Definition:The definition of work related violence that has received pan-European acceptance is as follows:...

by Wynne, Clarkin, Cox, & Griffiths (1997), explains it to involve incidents resulting in abuse, assault

Assault

In law, assault is a crime causing a victim to fear violence. The term is often confused with battery, which involves physical contact. The specific meaning of assault varies between countries, but can refer to an act that causes another to apprehend immediate and personal violence, or in the more...

or threats directed towards staff with regard to work–including an explicit or implicit challenge to their safety, well-being or health.

Aggression in the healthcare industry

Professions within the healthcare industry are becoming increasingly violent places in which to work–with healthcare professionals being common targets for violent and aggressive behaviour.

Aggression and violence

Violence

Violence is the use of physical force to apply a state to others contrary to their wishes. violence, while often a stand-alone issue, is often the culmination of other kinds of conflict, e.g...

negatively impact both the workplace and its employees. For the organisation, greater financial costs can be incurred due increased absences, early retirement and reduced quality of care. For the healthcare worker however, psychological damage such as post-traumatic stress

Post-traumatic stress disorder

Posttraumaticstress disorder is a severe anxiety disorder that can develop after exposure to any event that results in psychological trauma. This event may involve the threat of death to oneself or to someone else, or to one's own or someone else's physical, sexual, or psychological integrity,...

can result (Rippon 2000), in addition to a decrease in job motivation.

Classifying aggression

Classification (LeBlanc and Barling 2004):

Patient-on-Professional aggression can be classified as Type II; where the perpetrator commits a violent act whilst being served by the organisation, with which they have a legitimate relationship (LeBlanc and Barling 2004). It is uncommon for such attacks to result in death (Peek-Asa, Runyan, Zwerling 2001), however they are evidently responsible for approximately 60% of non-fatal assaults at work (Peek-Asa and Howard 1999).

Within this classification that is based on the relationship between the perpetrator and victim, Type I aggression involves the perpetrator entering the workplace to commit a crime

Crime

Crime is the breach of rules or laws for which some governing authority can ultimately prescribe a conviction...

–having no relationship to the organisation or its employees. Type III deals with a current/former employee targeting a co-worker or supervisor for what they perceive to be wrong-doing. Type IV aggression involves the perpetrator having an ongoing/previous relationship with an employee within the organisation. (LeBlanc and Barling 2004).

Conceptual Model 1 (Nijman et al. 1999)

Internal Model:

The internal model associates aggression with factors within the person, including mental illness

Mental illness

A mental disorder or mental illness is a psychological or behavioral pattern generally associated with subjective distress or disability that occurs in an individual, and which is not a part of normal development or culture. Such a disorder may consist of a combination of affective, behavioural,...

or personality

Personality psychology

Personality psychology is a branch of psychology that studies personality and individual differences. Its areas of focus include:* Constructing a coherent picture of the individual and his or her major psychological processes...

(Duxbury et al. 2008). This model is supported by the numerous studies correlating a link between aggression and illness (Duxbury and Whittington 2005). A person’s traits can relate to their expression of aggression–narcissists

Narcissism

Narcissism is a term with a wide range of meanings, depending on whether it is used to describe a central concept of psychoanalytic theory, a mental illness, a social or cultural problem, or simply a personality trait...

for example, tend to become angry and aggressive if their image is threatened (Anderson and Bushman 2002). Sex

Gender

Gender is a range of characteristics used to distinguish between males and females, particularly in the cases of men and women and the masculine and feminine attributes assigned to them. Depending on the context, the discriminating characteristics vary from sex to social role to gender identity...

tends to affect aggression–with certain provocations affecting each sex differently (Bettencourt and Miller 1996). It was found that males tend to prefer direct aggression, and females indirect (Österman et al. 1998) (Anderson and Bushman 2002). A study by Hobbs and Keane, 1996 explains that patient factors commonly related to or causative of patient violence include; male sex, relative youth or the effects of alcohol

Alcohol

In chemistry, an alcohol is an organic compound in which the hydroxy functional group is bound to a carbon atom. In particular, this carbon center should be saturated, having single bonds to three other atoms....

or drug

Drug

A drug, broadly speaking, is any substance that, when absorbed into the body of a living organism, alters normal bodily function. There is no single, precise definition, as there are different meanings in drug control law, government regulations, medicine, and colloquial usage.In pharmacology, a...

consumption (Hobbs and Keane 1996). A study conducted amongst General Medical Practitioners

General practitioner

A general practitioner is a medical practitioner who treats acute and chronic illnesses and provides preventive care and health education for all ages and both sexes. They have particular skills in treating people with multiple health issues and comorbidities...

in the West Midlands

West Midlands (region)

The West Midlands is an official region of England, covering the western half of the area traditionally known as the Midlands. It contains the second most populous British city, Birmingham, and the larger West Midlands conurbation, which includes the city of Wolverhampton and large towns of Dudley,...

found that men were involved in 66% of aggression cases; rising to 76% with regard to assault/injury

Injury

-By cause:*Traumatic injury, a body wound or shock produced by sudden physical injury, as from violence or accident*Other injuries from external physical causes, such as radiation injury, burn injury or frostbite*Injury from infection...

(Hobbs and Keane 1996)–the main male perpetrator being aged under 40 years of age. Patient anxiety, a particular problem associated with dentistry

Dentistry

Dentistry is the branch of medicine that is involved in the study, diagnosis, prevention, and treatment of diseases, disorders and conditions of the oral cavity, maxillofacial area and the adjacent and associated structures and their impact on the human body. Dentistry is widely considered...

, tended to be the most likely instigator for verbal abuse

Verbal abuse

Verbal abuse is best described as a negative defining statement told to you or about you; or by withholding any response thus defining the target as non-existant...

and the second most likely reason for threatening verbal abuse (Hobbs and Keane 1996).

External Model:

This model is based on the idea that social & physical environmental influences affect aggression (Duxbury et al. 2008). This includes the provisions for privacy

Privacy

Privacy is the ability of an individual or group to seclude themselves or information about themselves and thereby reveal themselves selectively...

, space and location (Duxbury and Whittington 2005). Motivation for aversion

Aversion

Aversion is a horror film about a private investigator who discovers too late that the woman he is hired to follow is often possessed by a demon. Alex Stokes is a self-destructive, down-on-his-luck investigator who takes cases wherever he can. When a mysterious man offers him a healthy sum to...

, possibly due to pain during dental treatment, can increase aggression (Berkowitz, Cochran, Embree 1981)–as can general discomfort, such as that resulting from sitting in a hot waiting room

Waiting room

A waiting room is a building, or more commonly a part of a building where people sit or stand until the event they are waiting for occurs.There are generally two types of waiting room. One is where individuals leave one at a time, for instance at a doctor's office or a hospital, or outside a school...

(Anderson, Anderson, Dorr 2000) or in an uncomfortable position (for example in a reclined dental chair) (Duxbury et al. 2008). Alcohol intoxication or excessive caffeine

Caffeine

Caffeine is a bitter, white crystalline xanthine alkaloid that acts as a stimulant drug. Caffeine is found in varying quantities in the seeds, leaves, and fruit of some plants, where it acts as a natural pesticide that paralyzes and kills certain insects feeding on the plants...

intake tends to indirectly exacerbate aggression (Bushman 1993). The Hobbs & Keane (1996) study states the involvement of drugs and alcohol; in 65% of cases at one Accident & Emergency Department and in 27% of all general practice cases. The study denotes intoxication to be the main reason for assaults and injury (along with mental illness) (Hobbs and Keane 1996). Frustration

Frustration

This article concerns the field of psychology. The term frustration does, however, also concern physics. In this context, the term is treated in a different article, geometric frustration....

, defined by Anderson and Bushman (2002) as “the blockage of goal attainment”, can also contribute to aggression–whether the frustrations are fully justified or not (Dill and Anderson 1995). Such frustration-related aggression tended to be against the perpetrator and persons not involved in failure to reach the goal. Prolonged waiting times in A&E departments and general practice led to aggression due to frustration; it generally being directed towards receptionist

Receptionist

A receptionist is an employee taking an office/administrative support position. The work is usually performed in a waiting area such as a lobby or front office desk of an organization or business...

s–with approximately 73% of doctors becoming involved (Hobbs and Keane 1996).

Situational/Interactional Model:

This deals with factors involved in the immediate situation, for example interactions between patients and staff (Duxbury et al. 2008). There a numerous studies that support the correlation between staff with a negative attitude and patient aggression (Duxbury and Whittington 2005). Provocation has been said to be the most important cause of human aggression (Anderson and Bushman 2002)–examples include verbal and physical aggression against the individual (Anderson and Bushman 2002). It was found that perceived injustice

Injustice

Injustice is the lack of or opposition to justice, either in reference to a particular event or act, or as a larger status quo. The term generally refers to misuse, abuse, neglect, or malfeasance that is uncorrected or else sanctioned by a legal system. Misuse and abuse with regard to a particular...

, in the context of equality

Egalitarianism

Egalitarianism is a trend of thought that favors equality of some sort among moral agents, whether persons or animals. Emphasis is placed upon the fact that equality contains the idea of equity of quality...

amongst staff for example, positively correlated to workplace aggression

Workplace aggression

Workplace aggression is a specific type of aggression, which occurs in the workplace. Workplace aggression can include a wide range of behaviors, ranging from verbal acts to physical attacks .-Definition:...

(Baron 1999).

Conceptual Model 2 (Baron 1999)

Expressions of Hostility:

This is related to “behaviours that are primarily verbal or symbolic in nature” (Baron 1999). In terms of Staff-on-Staff hostility

Hostility

Hostility is a form of angry internal rejection or denial in psychology. It is a part of personal construct psychology, developed by George Kelly...

, this can involve he perpetrator talking behind the targets back. With Patient-on-Professional hostility however, this can deal with the patient assuming false knowledge over the professional–with the patient belittling their opinions (Baron 1999).

Obstructionism:

This involves the perpetrator conducting actions that aim to “obstruct or impede the target’s performance” (Baron 1999). Failures to pass on information or respond to phone calls for example, are ways in which Staff-on-Staff obstructionism can be demonstrated. Patient-on-Professional obstructionism

Obstructionism

Obstructionism is the practice of deliberately delaying or preventing a process or change, especially in politics.-As workplace aggression:An obstructionist causes problems. Neuman and Baron identify obstructionism as one of the three dimensions that encompass the range of workplace aggression...

can be demonstrated by a failure on behalf of the patient to comply with the professional conducting a certain task. An unwillingness to allow the professional to diagnose

Diagnosis

Diagnosis is the identification of the nature and cause of anything. Diagnosis is used in many different disciplines with variations in the use of logics, analytics, and experience to determine the cause and effect relationships...

the patient and a failure to turn up to appointments are examples of such obstructionism.

Overt Aggression:

This normally relates to workplace violence, and involves behaviours including; threatening abuse, physical assault and vandalism

Vandalism

Vandalism is the behaviour attributed originally to the Vandals, by the Romans, in respect of culture: ruthless destruction or spoiling of anything beautiful or venerable...

(Baron 1999). This again can occur with regard to both, Staff-on-Staff and Patient-on-Professional aggression.

Buss’ Three-Dimensional Model of Aggression (1961)

Buss (1961) differentiated aggression into a three dimensional model; physical-verbal, active-passive and direct-indirect–active-passive being removed in 1995 when Buss refined the categories. Physical assault would come under the category physical-direct-active, whereas obstructionism relates to physical-passive–be it direct or indirect. Verbal abuse or insult

Insult

An insult is an expression, statement which is considered degrading and offensive. Insults may be intentional or accidental...

s relate to verbal-active-direct aggression, whereas the failure to answer a question when asked, for example with regard to lifestyle choices or habits, can come under the verbal-passive-direct category–providing the reasons for not answering are directed at the healthcare worker (e.g. hostility), as opposed to fear for example (Rippon 2000).

Prevalence of aggression within the healthcare industry

A survey from the British National Audit Office

National Audit Office (United Kingdom)

The National Audit Office is an independent Parliamentary body in the United Kingdom which is responsible for auditing central government departments, government agencies and non-departmental public bodies...

(2003) stated that violence and aggression accounted for 40% of reported health and safety incidents amongst healthcare workers (Oostrom and Mierlo 2008). Another survey looking into the violence and abuse experienced in 3078 general dental practices over a period of three years found that 80% of practice personnel had experienced violence or abuse within the workplace, which included verbal abuse and physical assault (Pemberton, Atherton, Thornhill, 2000). It was reported that, over 12 months in Australia

Australia

Australia , officially the Commonwealth of Australia, is a country in the Southern Hemisphere comprising the mainland of the Australian continent, the island of Tasmania, and numerous smaller islands in the Indian and Pacific Oceans. It is the world's sixth-largest country by total area...

n hospital

Hospital

A hospital is a health care institution providing patient treatment by specialized staff and equipment. Hospitals often, but not always, provide for inpatient care or longer-term patient stays....

s, 95% of staff had experienced verbal aggression (O'Connell et al. 2000). Moreover, in the UK over 50% of nurses had experienced violence or aggression over a 12-month period (Badger and Mullan 2004).

Coping with aggression in healthcare

When dealing with aggression and violence in the workplace, training

Training

The term training refers to the acquisition of knowledge, skills, and competencies as a result of the teaching of vocational or practical skills and knowledge that relate to specific useful competencies. It forms the core of apprenticeships and provides the backbone of content at institutes of...

and education

Education

Education in its broadest, general sense is the means through which the aims and habits of a group of people lives on from one generation to the next. Generally, it occurs through any experience that has a formative effect on the way one thinks, feels, or acts...

are the primary strategy for resolution (Beech and Leather 2006). There are a number or personal factors that can help reduce aggression within the healthcare setting, which include improved interpersonal skills

Interpersonal skills

Interpersonal skills are sometimes also referred to as people skills or communication skills. Interpersonal skills involve using skills such as active listening and tone of voice, this include delegation and leadership...

, with an awareness of patient aggression and knowledge regarding dealing with emotional patients (Oostrom and Mierlo 2008). Although assertiveness is crucial when it comes to the interpersonal skills possessed by healthcare workers, it has been shown by numerous studies that nurses tend not to be very assertive (Oostrom and Mierlo 2008). Training is therefore usually offered by organizations with regard to assertiveness

Assertiveness

Assertiveness is a particular mode of communication. Dorland's Medical Dictionary defines assertiveness as:During the second half of the 20th century, assertiveness was increasingly singled out as a behavioral skill taught by many personal development experts, behavior therapists, and cognitive...

, and deals mainly with improving self-esteem

Self-esteem

Self-esteem is a term in psychology to reflect a person's overall evaluation or appraisal of his or her own worth. Self-esteem encompasses beliefs and emotions such as triumph, despair, pride and shame: some would distinguish how 'the self-concept is what we think about the self; self-esteem, the...

, self-confidence

Self-confidence

The socio-psychological concept of self-confidence relates to self-assuredness in one's personal judgment, ability, power, etc., sometimes manifested excessively.Being confident in yourself is infectious if you present yourself well, others will want to follow in your foot steps towards...

and interpersonal communication

Interpersonal communication

Interpersonal communication is usually defined by communication scholars in numerous ways, usually describing participants who are dependent upon one another. It...

(Lin et al. 2004).

The Health Services Advisory Committee (HSAC) recommends a three-dimensional foundation by which to deal with violence in the workplace. It involves “researching the problem and assessing the risk, reducing the risk and checking what has been done” (Beech and Leather 2006).

In 1997, HSAC provided the following guidelines as to what good training involves (Beech and Leather 2006):

Theory: To understand the aggression within the workplace
Prevention: To assess the danger and take precautions
Interaction: With aggressive individuals
Post-Incident Action: To report, investigate, counsel, and follow up the incident

Assertive training (Lin et al. 2004)

Although many studies looking at the effectiveness of training have provided inconclusive results (Oostrom and Mierlo 2008), a study by Lin et al. (2004) positively correlated the improvement of assertiveness and self-esteem with an assertiveness training programme (Lin et al. 2004). The programme targets difficult interactions that we may face in day-to-day life and includes both, behavioural and cognitive techniques (Lin et al. 2004). The effectiveness of training is measured using the Assertive Scale, Esteem Scale, and Interpersonal Communication Satisfaction Inventory (Lin et al. 2004).

Evaluating the effectiveness of training

It remains that training is not universally or consistently offered to healthcare workers (Beech and Leather 2006). Beale et al. (1998) found that the levels of training offered ranged from nothing to high-level restraint/self-defense

Self-defense

Self-defense, self-defence or private defense is a countermeasure that involves defending oneself, one's property or the well-being of another from physical harm. The use of the right of self-defense as a legal justification for the use of force in times of danger is available in many...

training. A report by the National Audit Office (NAO) in 2003 found that, within mental health

Mental health

Mental health describes either a level of cognitive or emotional well-being or an absence of a mental disorder. From perspectives of the discipline of positive psychology or holism mental health may include an individual's ability to enjoy life and procure a balance between life activities and...

trusts, a reactionary approach tends to prioritise over prevention. Although criticised by many; restraint

Physical restraint

Physical restraint refers to the practice of rendering people harmless, helpless or keeping them in captivity by means such as handcuffs, fetters, straitjackets, ropes, straps, or other forms of physical restraint...

, seclusion

Seclusion

The act of secluding, i.e. shutting out or keeping apart from society, or the state of being secluded, or a place that facilitates it . A person, a couple, or a larger group may go to a secluded place for privacy, or because the place is quiet...

and medication

Medication

A pharmaceutical drug, also referred to as medicine, medication or medicament, can be loosely defined as any chemical substance intended for use in the medical diagnosis, cure, treatment, or prevention of disease.- Classification :...

are used (Wright 1999, Gudjonsson et al. 2004) (Duxbury and Whittington 2005). Breakaway techniques, restraint, rapid tranquilisation or isolation tend to be recommended when violence is instigated with a failure to prevent aggression (Duxbury and Whittington 2005). This correlates to the level of training offered, which dominates in these areas, however lacks in situation risk assessment

Risk assessment

Risk assessment is a step in a risk management procedure. Risk assessment is the determination of quantitative or qualitative value of risk related to a concrete situation and a recognized threat...

and customer care (Beech and Leather 2006)–methods that are vital in a preventative approach to prevent escalation of the situation, causing for reactionary measures to be brought into play.

The study by Beale et al. (1998) therefore provides the following advice as to good practice (Beech and Leather 2006):

Training should emphasise prevention, calming and negotiation
Negotiation
Negotiation is a dialogue between two or more people or parties, intended to reach an understanding, resolve point of difference, or gain advantage in outcome of dialogue, to produce an agreement upon courses of action, to bargain for individual or collective advantage, to craft outcomes to satisfy...

skills as opposed to confrontation
Training should be offered in modules, ranging initially from basic customer care and handling difficult patients to full control and restraint of patients.
Material relating to the causes of aggression, how to reduce risks, anticipation of violence, resolving conflict and dealing with post-incident circumstances should be provided to staff.
Physical breakaway skills should be taught–however an understanding as to situations in which such skills should be practiced must be appreciated.
Staff should be taught to control their own feelings
An understanding of normal/abnormal post-trauma reactions should be reached
Staff should be familiar with local arrangements and policies