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Nursing staff experiences and responses to violence and aggression in the emergency department: a grounded theory study

Nursing staff experiences and responses to violence and aggression in the emergency department: a grounded theory study

Ferns, Terence James (2011) Nursing staff experiences and responses to violence and aggression in the emergency department: a grounded theory study. EdD thesis, University of Greenwich.

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The aims of the study were to explore how emergency department (ED) nursing staff conceptualise the terms that encompass violence and aggression in the clinical area; to explore the formal reporting practices of nursing staff following such experiences and to explore situational factors at play, relating to the development of violent and aggressive incidents in the ED setting.


Violence and aggression experienced by ED nursing staff is a well recognised, global phenomenon. Published research exploring ED violence and aggression however is limited, both numerically, and in terms of quality and sophistication. The literature review conducted for this study identified very few studies that considered defining violence and aggression in the ED setting. The literature suggests that ED nursing staff frequently fail to formally report experiences of violence and aggression and factors influencing reporting practices tend to be speculated upon rather than researched. A wide variety of situational factors are identified in the literature as contributing towards violence and aggression in the ED setting, although, only a limited number of original research papers have contributed new knowledge in this field. This study was subsequently conducted for the award of a Doctorate of Education and focuses upon educational factors, within the context of the research aims and emerging themes that can be perceived as relevant to the phenomenon of ED violence.

Methodology and research design

The study was undertaken from August 2007 to May 2009 at a site specific, National Health Service (NHS), acute hospital ED in the south of England. Adopting an interpretive paradigm, data was collected and analysed within a grounded theory framework. Data triangulation was employed, with the researcher conducting a retrospective documentary inspection of ED violent incidents forms completed by nursing staff (n=38), semi-structured interviews with ED nursing staff (n=9) and periods of non- participant, unstructured observation (n=17).


The study identified multiple examples of conflict in the ED, including nursing staff personally experiencing, witnessing, or being aware of physical assaults on staff. This included both physical assaults involving weapons, along with high levels of verbal abuse. The study also identified the phenomenon of service user-on-service user conflict, an issue previously not considered in ED literature.

The findings highlighted that individual nursing participants considered a variety of complex factors when subjectively and inconsistently defining, assessing, managing, responding to and reporting workplace conflict. A wide variety of inter-related factors contributed to how participants defined violence and aggression, although the dominant theme that emerged related to inconsistent practice. A failure to clarify the concepts encompassing violence and aggression contributed towards a culture of under-reporting of incidents; although incident frequency and a perception by participants that formal reporting was a futile exercise that did not lead to change, were also highlighted.

Some participants expressed a disempowered attitude towards working conditions, which limited a proactive approach to maximising personal safety in the department studied. A cocktail of potential situational factors was in addition identified, as contributing to conflict in the ED studied, in particular: poor corporate security, poor departmental design and infrastructure, negative service user attitude and behaviour. Stress, service user demographics, confrontational staff communication strategies and a limited proactive approach to managing violence and aggression in a professional manner at both personal and corporate levels were also cited.

Although the study had 3 pre-determined research aims; from an educational perspective, 4 key themes emerged. These related to a limited evidence-based approach to managing ED violence, due to a paucity of research; particularly research conducted by clinical nursing staff. Inconsistent practice in assessment, management and reporting of ED violence, challenging working conditions compromising personal safety and stifling potential research opportunities, and a disempowered attitude displayed by some participants in relation to managing their occupational circumstances proactively. The data collected, during this study, in addition, highlighted multiple examples of participants being aware of, or potentially being involved in, practices that contravene the Nursing and Midwifery Council (2008) Code of conduct, performance and ethics for nurses and midwives.


The data collected during this study can be interpreted as suggesting that ED violence and aggression is poorly documented; the subject matter remains unclarified in clinical practice; specific incidents of violence and aggression are inconsistently assessed and managed and that there is a cocktail of factors which contributes towards the development of conflict in the ED.

Two central, core categories were identified during this work; and labelled as professional nursing identity, and professional maturity. The findings of this site specific study challenge the foundations of the nursing profession in terms of claims of professional status, as the data collected is incongruent with the characterisation of the attributes and traits of professional status.

Nursing identity relates to participants expressing widely differing views relating to the actual role of the ED nurse. This subsequently manifests as variations in the documentation, assessment, management and attitude of staff towards service users involved in conflict with staff.

Professional maturity relates to the limited research literature available examining this field, particularly research conducted by clinical nursing staff. This can be interpreted as reflecting a wider professional failing to embed a genuine research culture into the nursing profession. Professional maturity also relates to participants complying with the NMC code (2008).

One can propose that as the nursing profession develops and matures, individual members may project enhanced professional values which could lead to improved workplace circumstances. Currently, ambiguity and inconsistent practice characterise the nursing response to ED violence. This may be potentially rectified through a variety of higher educational (HE) initiatives designed to proactively and positively influence the two central core categories identified above.

Educational recommendations relate to encouraging a policy shift in the HE sector to promote the development of genuine professional autonomy. This could be achieved through placing emphasis on facilitating the development of under-graduate nursing students as potential future researchers; by formally requiring under-graduate degree nursing students to engage in original data collection research activities. HE institutions should also strive to empower under-graduate nursing students to challenge current occupational workplace conditions, through a transformational leadership approach emphasising the development of confident, assertive, and politically astute nurses of the future.

Clarification relating to defining violence and aggression in the healthcare context, a review of current formal reporting procedures, a review of corporate security at the site examined, a wider debate relating to the role of the ED nurse, and increased research and education focusing upon ED violence and aggression are all suggested as further recommendations.

Item Type: Thesis (EdD)
Additional Information:
Uncontrolled Keywords: violence, aggression, nhs, working conditions, clinical practice,
Subjects: R Medicine > R Medicine (General)
R Medicine > RA Public aspects of medicine
Pre-2014 Departments: School of Education
School of Education > Department of Professional Learning & Development
Last Modified: 14 Oct 2016 09:20

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