NURSING AFTER SUNSET
Violence & Aggression from a
Night Shift Perspective
Mr. Joseph Galea RMN, RGN.
B.Sc.(Hons.) Mental Health Nursing, BBA(Hons.) Business Administration,
Cert. Subst. Misuse (UK)
Departmental Nursing Manager - MCH
MAPN Conference
2nd November 2012
Aims of the Presentation
1. Antecedents to Violence
& Aggression
2. Night-Shift & Violence
3. Effects of Violence &
Agression
4. Deescalation of a Crisis
5. Night-Shift
6. Effect of Night-Shift
7. Sleep Disorders &
Fatigue
8. Under-reporting of
Violence & Aggression
Incidents
9. Recommendations
2
Introduction (i)

Prevelance of violence in healthcare (Duncan et
al., 2001; Gerberich et al., 2004; Lanza, Zeiss & Reirdan, 2006a)

Particularly on nursing staff
(Findroff et al., 2004;
Hodgson et al., 2004; Lanza, Zeiss & Reirdan, 2006b)

Impact on the physical & psychological
health (Gerberich et al., 2004; Lanza, 1983, 1992; Lanza et al., 2006a; Woods &
Ashley, 2007)

Impact on the ward environment and
patients’ care (Flannery et al., 1995; Morrison, 1990)
3
Antecedents to Violence &
Aggression (i)

Perpetrators of physical violence = patients (Acik et al., 2008;
Chen et al., 2008)

Lateral violence = perpetrators of psychological
violence = staff members, co-workers & supervisors
(King & McInerney, 2006; Kwok et al., 2006; Johnson et al., 2007; Bigony et al., 2009)


Reasons for aggressive & violent behaviour – patients
and nurses disagree – patients: environmental
conditions + poor communication; nurses: patients’
mental illness (Duxbury & Whittington (2005)
Complex interactions of patients, staff and culture of a
specific unit (Hamrin et al., 2009)
4
ANTECEDENTS to
Violence and Aggression
1) Patient –
Patient
Interaction
8) Patient
Symptoms
2) Staff-Patient
Interaction
Medication Related
Containment
Any other
containment
Any other staff-patient
interaction
Violence &
Aggression
3) Patient
Conflict
Behaviors
7) Patient
Emotional
Cues
5) Structural
Issues
Environmental
Issues
4) External /
Personal Issues
Regime
Issues
6) Patient
Behavioral
Cues
5
Patient to Patient Interaction
(Bowers et al. 2011)


Physical contact
Intrusion into personal
psychological or physical
space (BAAEM, 2003; McPhauls & Lipscomb,
2008; May & Grubbs, 2002; Presley & Robinson,
2002)



Competition
Patient engaged in an activity
Reaction to sexual approach



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
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Miscummunication
Victim doing something
patient wanted stopped
Retaliation
Patient victim characteristics
Teased / bugged
Provocation (Powell et al., 1994)
Difference in language and
culture (Mallet & Dougherty, 2000)
6
Staff-Patient Interaction

Limiting patients’ freedom:

(Sheridan et al., 1994; Lancee et al., 1995; Davis, 1991)
and the limit style of nursing staff
(Lancee et al., 1995; RCP, 2000)

Medication related
containment:



a) medication administration,
b) staff requesting patient to take
medication,
c) dispute over medication (Sheridan et al.,
1990; Powell et al., 1994; Lancee et al., 1995; Davis, 1991)

Any other containment:





a) restraint,
b) seclusion,
c) de-escalation,
d) ECT,
e) involuntary admissions (Fineberg et al.,
(Bowers et al. 2011)
Any othe staff-patient interaction:








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

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a) provocation.
b) ordering patients,
c) intervening on fight or argument,
d) caring for patient,
e) searching patients,
f) negative staff attitude (OSHA, 2003; BAAEM, 2003),
g) physical contact,
h) patient engaged in an activity,
i) miscommunication,
j) staff too permissive,
k) staff victim characteristics,
l) staff errors,
m) violation of priority (Mallet & Dougerty, 2000),
n) lack of information (Mallet & Dougherty, 2000),
o) access to staff (McGeorge et al., 2000).
1990; Powell et al., 1994)
7

Patient conflict Behaviors
2011)


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
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
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a) threatening behaviour,
b) abscondments,
c) substance misuse (BAAEM, 2003; Johnson, 1997),
d) verbal agression,
d) self-harm.
(Bowers et al. 2011)

:
a) money issues,
b) visit from family member or friend (Henry &



c) receiving bad news,
d) unresolved family problem.
a) overcrowding (Fineberg et al., 1990; Palmstierna et al., 1991; Lanza et
al., 1994),



b) confined environment,
c) noisy ward,
d) patients found weapons,
e) social environment such as boredom (RCP, 1998;
RCP, 2000).
b) admitting / transferring /
discharged & when pts ask to
discharge themselves against medical
advice (Sheridan et al., 1990; Powell et al., 1994; Lancee et al., 1995;
Davis, 1991),




c) excessive sensory stimulation,
d) lack of stimulation.
Patient Behavioral cues (Bowers et al. 2011) :

(Bowers et al. 2011)

a) inadequate staffing levels (McPhaul &
Lipscomb, 2008; Gilmore-Hall, 2001,
Structural & Environmental
issues
:

Regime issues (Bowers et al. 2011) :

Ginn, 2002) (BAAEM, 2003),


:
External / Personal

(Bowers et al.
a) agitation,
b) attention seeking behavior,
c) increased motor activity,
d) confusion.
Patient emotional / mood cues
(Bowers et al. 2011) :





a) anger,
b) sexual frustration,
c) irritability,
d) tobacco withdrawal,
e) Delusions (Humphreys et al., 1992) &
hallucinations (Dura, 1997), and stress due
pain or illness (ICN, 2002; McPhauls & Lipscomb, 2008).
8
Night-Shift & Violence (i)




Violence experienced during night-shifts (Arnetz et
al., 1996) particularly before 11pm.
Mostly occured during the afternoon – 3pm to
11pm (Bradley et al., 2001) – lack of structured
interaction (Drinkwater, 1982; Rice et al., 1989)
There is no consensus.
Specific times for aggression: during admission
– change of shifts – mealtimes (Pearson et al., 1986) –
visiting hours (Way et al., 1992) – administration of
medication (Walker & Siefert, 1994; Barnard et al., 1984; Depp, 1983).
9
Figure 1: Peak times for violent incidents
14
F
R
E
Q
U
E
N
C
Y
12
10
8
6
4
2
0
6.007.59
Bowers et al., 2011
8.0011.59
12.0011.59
14.0017.59
18.0019.59
20.0021.59
22.005.59
TIME
10
Night-Shift & Violence (ii)

Highest numbers of incident occurred between 7am –
3.30pm (morning shifts, 49% of the incidents); high
number on afternoon shift (36%); during night (15%)
(Barlow et al., 2000)

Aggression a daytime phenomenon (Barlow et al., 2000; Way et al.,
1992; Shah et al., 1991)

Patients on leave – evening on return to the ward (Nobel &
Rodger, 1989)




Preventing a patient leaving the ward (Walker & Siefert, 1994)
Staff uncertain of their roles (Katz & Kirkland, 1990)
Substitute nursing staff (James et al., 1990)
Higher staff to patient ratio (Morrison, 1990; Kalgerakis 1973; Depp, 1983)
– more than 1:1 (Lanza et al., 1994)
11
FIG 1: Peak shifts for
violent incidents
FIG 2: Location of
violent incidents
16
F
R
E
Q
U
E
N
C
Y
30
14
25
12
%
10
20
8
15
6
10
4
5
2
0
0
Bathroom Bedroom
Day
Morning
Afternoon/Evening
Night
SHIFT
Corridor
Dining
Room
Lounge Nurse office Ward door
LOCATION
Bowers et al., 2011
12
Victims of in-patient
violence

Staff – nurses
(90% of incidents)
(Edwards et al., 1988; Noble &
Rodger, 1989)

Patients (30%)
were against
patients (Noble & Rodger,
1989)

Provoked by
patients, relatives
or visitors (Powell et al.,
1994).


Effects of Violence &
Aggression
Physical injuries (Chen et al., 2008)
Psychological trauma (Chen et al., 2008)
& PTSD (Caldwell, 1992; Mikkelsen & Einarsen, 2002;
Hansen et al., 2006; Bigony et al., 2009)



Negative impact on the mental
health of nurses (Pai & Lee, 2011)
Emotional reactions following
violence include antipathy
against perpetrator, insult and
fear (Astrom et al., 2004)
Negative organisational
outcomes (Estryn-Behar et al., 2008;
DHHS/NIOSH, 2002)
13
De-escalation of a Crisis

‘Calming the patient’ – shift from a dominantsubmissive connotation to collaboration (Richmond et
al., 2012).


De-escalating a patient = form of a treatment =
develop internal locus of control (Richmond et al., 2012).
This involves rapid assessment & decisionmaking skills
14
Skills Needed (Richmond et al., 2012)

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
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Good attitude
Observation skills – verbal &
non-verbal skills
Risk Assessment skills
Communication skills
Listening skills (active
listening)
Active listening skills
Emotional intelligence – selfmonitoring
Positive regard
Empathic






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

Quick decision making skills
Assertiveness skills
Team coordination skills
Coaching skills
Limit settings
Motor skills
Offer choices and optimism
Restraining skills
Debriefing skills
15
Night-Shift (i)



Work performed after 6pm and before 6am the
next day. (Abdalkaber & Hayajneh, 2008)
Activity at night = out of phase with the
circadian body temperature. = desynchronised
state. (Abdalkaber & Hayajneh, 2008)
This disorientation = health & psychological
effect of fatigue. (Abdalkaber & Hayajneh, 2008)
16
What these three sets of
pictures have in common?
(Rogers et al., 1997; Harrington, 2001)
17
Night-Shift (ii)


To ensure patient’s coverage nurses have to work nights,
weekends and holidays.
Night nurses have higher levels of fatigue (Muecke, 2005)
and mental tiredness (Tepas et al., 2004), chronic sleep loss,
sleep deprivation and on-the-job sleepiness (Hughes & Stone,
2004).



Rarely get the recommended 8 hrs of sleep (Akerstedt, 2003).
Suffer from sleep disturbances (Barton, 1994) – which may
have an impact on patients’ safety.
Less quality sleep then those working during the day
(Ruggiero, 2003; Frank & Ovens, 2002).

Sleep deprivaton – work performance outcomes –
safety and general health of the nurse (Rogers et al., 2004)
18
Night-Shift (iii)




The 2nd half of the night is where nurses reported that
they frequently struggle to stay awake (Berger & Hobbs, 2006).
Staff ’s circadian rhythm – social – family life – general
health affected (Rosa & Collingan, 1997).
Nurse who work nights are more depressed than day
nurses (Ruggiero, 2003) / there is an association between night
work and poor job satisfaction (Korompeli et al., 2009).
Staff performance: Significant associations between
night staff and error rate (Gold et al., 1992; Leff et al., 2008).
19
Effects of Night-Shifts

Two things wrong with shift-work:






Having to work when supposed to sleep
Having to sleep when supposed to be awake
For some people, this can result in performance, health and
social effects
Fatigue = less work performance + short staffing = less
the quality of patient care (Circadian Technologies, 2004)
Breast Cancer to be 60% higher in women night-shift
workers (Humm, 2005; Swerdlow, 2003; Steven & Davis, 1996) infertility,
cardiovascular disease, diabetes and gastrointestinal
disorders (Humm, 2005; Reid et al., 1997; Learhart, 2000).
Fatigue, irritability (Lushington et al., 1997; Reid et al., 1997), reduced
performance, decreased mental agility (Alward & Monk, 2003).
20
Circadian Rhythms

Fatigue = impair memory, vigilance, reaction time, and
communication = cyclic reductions in alertness and performance
(Howard et al., 2002).





Internal body clock – external world (zeitgebers)
High activity during the day – low activity during the night
Human race is diurnal
Health problems (Crofts, 1999), negative effects: for the individual &
the work place – decreased alertness & reduced job performance
– affect the quality of care (Koller, 1996; Brown & Erkes, 1998)
Optimum mental performance level (2-4pm) and maximum
general awareness is between (1-7pm. Performance levels are
lowest between 3.30 – 5.30am (Coffey et al., 1998)
21
Sleep Disorders (i)





Lack of sleep (Coffey et al., 1998)
Sleep disorder – tiredness – reduced functional capacity
Functional capacity may be halved after 24 hrs and after
48 hrs is at its lowest
Complex decisions (Akerstedt, 1999) though short term
memory recall is not effected (Allen, 1999)
Sleep deprivation – disrupt the circadian rhythm –
forces the body to function at night despite signals (i.e.
Decreased body temp. & increased melatonin (Hughes &
Stone, 2004)
22
Sleep Disorders (ii)






Sleep quantity and sleep quality affected especially with night
work
Daytime sleep not as deep or refreshing
Worse when room is not quite, not dark and not comfortable
Sleep quantity: Night shift (4-6 hrs) – Day shift (7.5 hrs) –
Evening (8.5 hrs)
Sleep quality: day sleep – less deep sleep (stage 3 – 4); Rotating
shift < Permanent shift
Sleep deprivation of 24 hours affect performance level (blood
alcohol levels of 0.10%) (Dawson & Reid, 1997). Mature vs young
night shift workers (Reid & Dawson, 2001).
23
The Combination of Night Shift
Nursing with Aggression & Violence
Night shift related fatigue and
sleep difficulties
Skills required when dealing with violence &
aggression
(Bonnet, 2000; Harrison & Horne, 2000)










Negative mood
Sleep loss and fatigue
Lack of innovation and
creativity
Increased distractability
Inability to deal with
unexpected events
Inability to deviate from
previous problem-solving
strategies
Unreliable temporal memory
Impaired language skills
Motor skill performance can
be impaired (Eastridge et al., 2003;
Grantcharov et al., 2001)
Skill error increase (Taffinder et
al., 1998)

















Good attitude
Observation skills – verbal & non-verbal skills
Risk Assessment skills
Communication skills
Listening skills (active listening)
Active listening skills
Emotional intelligence – self-monitoring
Positive regard
Quick and empathic decision making skills
Assertiveness skills
Team coordination skills
Coaching skills
Limit settings
Motor skills
Offer choices and optimism
Restraining skills
Debriefing skills
24
Under-Reporting of Violence

Insufficient post-incident support (Pai & Lee, 2011; Kwok et al., 2006; Kamchuchat
et al., 2008)





Stigma of victimisation (Hoff, 1992)
Accepted as a hazard of the profession (Daldt, 1981); part of the
job (Poster, 1996; Prins, 1999)
Resistance from hospital administrators (Lanza, 1991)
Peer nursing pressure (Kinross, 1992)
Poor or ineffective reporting mechanisms (Lyon et al., 1981; Pearson et al.,
1986; Silver & Yudofsky, 1987; Lanza, 1988; Monahan, 1989)

Lack of support from organisation (Paterson et al., 1999) but staff was
supported by their immediate nursing colleagues (McGeorge et al.,
2000)

Lack of institutional reporting policies, employees beliefs
and concerns (Sofiel & Salmond, 2005); Ferns, 2005; May & Grubbs, 2002, US Dept of Labor, 2008)
25
Recommendations









Managment awareness – planning shift schedules – aware of
biological rhythms.
Regular medical screening & breast screeing for night female nurses
over 40 years of age
For health reasons – option to day work – option to night work
Critical incident stress debriefing or therapy
Training & Re-organisation of the ward routine (McGeorge et al., 2000)
Increasing face-to-face contact
Improving information sharing
Interaction with staff and patients
A significant amount of workplace aggression is preventable (DelBel, 2003).
Education programs for nurses on fatigue and night work (Circadian
Techologies, 2004)

Violence prevention programs (Kindy, 2005; Anderson & Parish, 2003; Gilmore-Hall, 2001;
McPhaul & Lipscomb, 2008; US Dept of Labor, 2008)
26
Conclusion





Link = human interaction & violence
Less incidents during the night – atmosphere
tend to be more quiter
The organisation of ward routine
Staff-patient interaction = associated with
violence
Good practioner during day not necessarily
mean good practitioner during the night.
27
Final thought......
‘THE BEST FIGHTER IS NEVER ANGRY’
................ Lao Tzu
‘but never tired ’.......
28
THANK YOU
29
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