King Saud UniversityCollege of Nursing
Master’s Degree Program
1st Semester, 1444 H
Assignment 4
Each student must critique the attached published research paper (at
least 300 words).
Deadline:
This homework should be sent to Areem@ksu.edu.sa from your KSU
student’s email (one time) by Sunday 09 October 2022 at 12:00 pm
Original article
Violence in the emergency department: a multicentre
survey of nurses’ perceptions in Nigeria
Kolawole Olubunmi Ogundipe,1,2 Amarachukwu Chiduziem Etonyeaku,3,4
Ismaila Adigun,5 Emmanuel O Ojo,6,7,8 Tunde Aladesanmi,9 Jones O Taiwo,10
Obitade Sunday Obimakinde11
▸ Additional supplementary
files are published online only.
To view these files please visit
the journal online (http://dx.doi.
org/10.1136/emermed-2012201541).
1
Division of Plastic and
Reconstructive Surgery,
Department of Surgery, Ekiti
State University Teaching
Hospital, Ado-Ekiti, Ekiti,
Nigeria
2
Department of Accident and
Emergency, Ekiti State
University Teaching Hospital,
Ado-Ekiti, Ekiti, Nigeria
3
Department of Surgery,
Obafemi Awolowo University,
Ile-Ife, Osun, Nigeria
4
Department of Surgery,
Federal Medical Centre, Owo,
Ondo State, Nigeria
5
Division of Plastic and
Reconstructive Surgery,
Department of Surgery,
University of Ilorin Teaching
Hospital, Ilorin, Kwara, Nigeria
6
Department of Surgery, Jos
University Teaching Hospital,
Jos, Plateau, Nigeria
7
Department of Surgery, Ekiti
State University Teaching
Hospital, Ado-Ekiti, Ekiti,
Nigeria
8
Department of Surgery, State
Specialist Hospital, Yola,
Adamawa, Nigeria
9
Department of Surgery,
Federal Medical Centre,
Ido-Ekiti, Ekiti, Nigeria
10
Department of Surgery,
Federal Medical Centre, Lokoja,
Kogi, Nigeria
11
Division of Oral and
Maxillofacial Surgery, Ekiti
State University Teaching
Hospital, Ado-Ekiti, Ekiti,
Nigeria
Correspondence to
Dr Amarachukwu Chiduziem
Etonyeaku, Department of
Surgery, Obafemi Awolowo
University, Ile-Ife,
Osun State +234, Nigeria;
dretonyeaku@gmail.com
Accepted 1 September 2012
Published Online First
4 October 2012
758
ABSTRACT
Background Emergency department (ED) violence is
common and widespread. ED staff receive both verbal
and physical abuse, with ED nurses bearing the brunt of
this violence. The violence is becoming increasingly
common and lethal and many institutions are still
improperly prepared to deal with it.
Methods A questionnaire based survey of the
perception of violence among nurses working in six
tertiary hospitals’ EDs across five states in Nigeria was
conducted.
Results 81 nurses were interviewed with a male to
female ratio of 1:4. Most were right about the definition
of violence. About 88.6% of respondents have witnessed
ED violence while 65.0% had been direct victims before.
Nurses followed by doctors were the usual victims. The
acts were carried out mostly by visitors to the ED. Men
were usually responsible for the violence, which usually
occurred in the evenings. Weapons were not commonly
utilised: only 15.8% of the nurses had been threatened
with a weapon over a 1-year period. The main perceived
reasons for violence were overcrowded emergency
rooms, long waiting time and inadequate system of
security. All the institutions were lacking in basic
strategies for prevention. While most of the nurses were
not satisfied with the EDs that were considered not
safe, few would wish for redeployment to other
departments/units.
Conclusions There is a need to make the EDs safer for
all users. This can be achieved by a deliberate
management policy of ‘zero’ tolerance to workplace
violence, effective reporting systems, adequate security
and staff training on prevention of violence.
INTRODUCTION
There is no doubt that we live in a violent society,
with violence in our streets, in our schools, in our
homes and in our hospitals. Emergency department (ED) violence is common and widespread.1
The ED is a major portal of entry for patients into
the hospital. It is said to be the barometer of how
well the healthcare system is working.2 EDs are
high-stress areas where many patients may have
conditions consequent on trauma, and they or
their relations could have labile emotions that may
predispose to violence against caregivers. Research
suggests that staff in the ED receive the most
amount of verbal and physical abuse compared to
other departments.3 Nurses bear the brunt of this
violence.4 Violence in our EDs is becoming increasingly common and lethal.5 The available evidence
still suggests that many institutions are improperly
prepared to deal with it.6 While studies on violence
against workers in the psychiatry and dental services in our country have been performed,7 8 we
sought to determine the epidemiology of violence
against nurses working in the ED, their perception
of what constitutes violence, effects of such violence on productivity and potential preventive
strategies.
MATERIALS AND METHODS
This study was conducted at six tertiary institutions spread across five states in Nigeria:
1. University Teaching Hospital, Ado-Ekiti, Ekiti
State (UTH Ado)
2. Federal Medical Centre, Ido-Ekiti, Ekiti State
(FMC Ido)
3. Federal Medical Centre, Owo, Ondo State
(FMC Owo)
4. State Specialist Hospital, Yola, Adamawa State
(SSH Yola)
5. Federal Medical Centre, Lokoja, Kogi State
(FMC Lokoja)
6. University of Ilorin Teaching Hospital, Ilorin,
Kwara State (UITH Ilorin)
The EDs in these hospitals are staffed 24 h a day
by certified nurses, some of whom are certified
emergency nurses. Ethical clearance was obtained
from the participating hospitals’ ethics and
research committees. A semi-structured questionnaire was distributed to all certified nurses
working in the EDs of the hospitals at the time of
the study. The questionnaires probed the respondents’ definitions of violence, their perception of
the epidemiology, the number of violent encounters in the last 1 year, causes of violence and available strategic measures for prevention. The effect
of violence on job performance, job satisfaction
and career choice were also assessed. Finally, the
attributes possessed by nurses in reducing, averting
or preventing violence were probed. All the information was managed with strict confidentiality.
Nurses working in the children’s, and gynaecology and obstetrics emergency services were
excluded from the study.
Data collection in all the hospital was completed within 2 months—October and November
2009.
The data were entered into a Microsoft Excel
2007 spreadsheet and analysed using SPSS V.15.
They were then summarised with medians for
skewed continuous and ordinal data, means for
normally distributed continuous data and proportions for categorical data.
Emerg Med J 2013;30:758–762. doi:10.1136/emermed-2012-201541
Original article
Table 1
Hospital distribution of the respondents and gender
Sex of respondents
Centre of study
Unspecified count
Male count
Female count
Total count
UTH Ado
FMC Ido
FMC Owo
UITH Ilorin
FMC Lokoja
SSH Yola
Total
0
3
3
3
1
0
10
3
0
1
1
3
6
14
9
12
16
11
6
3
57
12
15
20
15
10
9
81
FMC Ido, Federal Medical Centre, Ido-Ekiti, Ekiti State; FMC Lokoja, Federal Medical
Centre, Lokoja, Kogi State; FMC Owo, Federal Medical Centre, Owo, Ondo State;
SSH Yola, State Specialist Hospital, Yola, Adamawa State; UITH Ilorin, University of
Ilorin Teaching Hospital, Ilorin, Kwara State; UTH Ado, University Teaching Hospital,
Ado-Ekiti, Ekiti State.
RESULTS
A total of 81 nurses with a male to female ratio of 1:4 from the
six institutions completed the questionnaire, giving a response
rate of about 90%. Ten of the respondents did not indicate their
sex in the completed questionnaire. The geographical spread of
the nurses is shown in table 1.
The age of the nurses ranged from 25–57 years with a mean
age of 39.33 years (SD 9.58 years). The mean number of postqualification years and number of years of work experience
in the ED were 13.2 years (range 1–30 years, SD 8.86 years)
and 5.3 years (range 1–28 years, SD:7.01 years), respectively.
The majority of respondents were married (72.4%); others were
either single (23.7%) or widowed (3.9%). Respondents were
Christians (86.8%), Muslims (11.8%) or atheists (1.3%). Most
were correct about the definition of violence (81.2%). While
88.6% of the nurses had witnessed ED violence, only 65.0%
had been direct victims before. Nurses followed by doctors
were the usual victims of the ED violence in all institutions.
These acts were carried out mostly by visitors ( patients’ relatives or friends) to the ED. (figure 1A,B). Men, women and
both sexes were responsible for the violence in 76.6%, 10.4%
and 13.0% of cases, respectively. Even though most violence
took place in the evening (38.0% of times), there was a statistically significant difference in the time of the day that violence
was experienced among the various hospitals (table 2).
Only 15.8% of the nurses were ever threatened with a
weapon over the preceding year. Table 3 illustrates the perceived
reasons for violence in the various institutions.
All the institutions were lacking in basic strategies for prevention. Table 4 illustrates the mean rating of the various strategies commonly employed in the prevention of violence.
Figure 1 Perception of the nurses on the usual victims (A) and the
usual architects (B) of emergency department violence (EDV). FMC Ido,
Federal Medical Centre, Ido-Ekiti, Ekiti State; FMC Lokoja, Federal
Medical Centre, Lokoja, Kogi State; FMC Owo, Federal Medical Centre,
Owo, Ondo State; UTH Ado, University Teaching Hospital, Ado-Ekiti,
Ekiti State; UITH Ilorin, University of Ilorin Teaching Hospital, Ilorin,
Kwara State; SSH Yola, State Specialist Hospital, Yola, Adamawa State.
Access the article online to view this figure in colour.
Despite these generally poor preventive strategies, 74.3% of
the respondents have not had any form of training on recognising and/or managing violence. For those who had some form
Table 2 Frequency of time of occurrence of violence in the centres of study
Centre of study
Time of day that most episodes of
violence are experienced
UTH Ado
N (%)
FMC Ido
N (%)
FMC Owo
N (%)
UITH Ilorin
N (%)
FMC Lokoja
N (%)
SSH Yola
N (%)
Subtotal
N (%)
Morning
Afternoon
Evening
Night
Any time
0.0
27.3
54.5
9.1
9.1
25.0
33.3
16.7
16.7
8.3
26.7
13.3
13.3
0.0
46.7
42.9
21.4
14.3
14.3
7.1
20.0
0.0
70.0
10.0
0.0
0.0
11.1
88.9
0.0
0.0
21.1
18.3
38.0
8.5
14.1
FMC Ido, Federal Medical Centre, Ido-Ekiti, Ekiti State; FMC Owo, Federal Medical Centre, Owo, Ondo State; FMC Lokoja, Federal Medical Centre, Lokoja, Kogi State; SSH Yola,
State Specialist Hospital, Yola, Adamawa State; UTH Ado, University Teaching Hospital, Ado-Ekiti, Ekiti State; UITH Ilorin, University of Ilorin Teaching Hospital, Ilorin, Kwara
State.
Emerg Med J 2013;30:758–762. doi:10.1136/emermed-2012-201541
759
Original article
Table 3 Average points for the rating on a scale of 0–5 for individual reasons for ED violence in the centres of study
Centre of study
Reasons given for ED violence
UTH Ado
Mean
FMC Ido
Mean
FMC Owo
Mean
UITH Ilorin
Mean
FMC Lokoja
Mean
SSH Yola
Mean
Subtotal
Mean
Drug induced or related violence
Overcrowded ERs
Understaffed ED
Long waiting time and frustration of patients/relatives
Inadequate system of security
The culture of silence/poor communication with patients
Lack of institutional concern and systems
Lack of reporting of previous episodes of violence
Demand of triage
Domestic quarrels that are brought to the ED
Length of stay in the ER before transfer
Pain and anger experienced by ED users
Alcoholism
Spread of gangs/cultist/thugs
Keeping of psychiatric patients with others
Unrealistic expectations of patients
Transfer of child, elder, or spousal abuse to ED staff
Neglect of patients who require urgent attention
3.09
4.42
4.08
3.55
3.42
2.50
3.30
2.33
1.63
1.50
2.50
2.92
4.17
3.92
3.33
3.58
2.67
2.42
2.15
4.00
3.53
4.07
3.60
2.31
2.29
2.21
2.17
2.36
2.93
2.79
2.93
2.40
3.29
2.92
2.14
2.64
2.23
4.00
4.06
4.40
3.63
1.87
1.38
2.20
2.27
2.00
3.56
2.86
2.36
2.00
2.87
2.79
2.53
1.67
1.75
3.08
2.62
3.54
3.62
2.25
2.46
3.27
2.62
2.69
3.46
2.38
2.38
1.69
1.33
2.82
2.18
2.64
3.30
4.10
2.90
3.70
4.20
2.70
3.60
3.30
1.00
2.67
2.00
3.20
4.20
4.10
2.40
2.78
1.63
2.67
4.25
3.78
4.22
3.78
3.89
2.33
3.00
2.88
2.75
3.00
2.44
2.56
4.11
3.50
1.50
3.00
2.67
2.33
2.67
3.91
3.57
3.88
3.69
2.30
2.53
2.63
2.11
2.32
2.92
2.78
3.25
2.79
2.55
2.99
2.33
2.36
The highest and the next highest mean values of reasons of violence of individual centres are highlighted in bold.
ED, emergency department; ER, emergency room; FMC Ido, Federal Medical Centre, Ido-Ekiti, Ekiti State; FMC Lokoja, Federal Medical Centre, Lokoja, Kogi State; FMC Owo,
Federal Medical Centre, Owo, Ondo State; UTH Ado, University Teaching Hospital, Ado-Ekiti, Ekiti State; UITH Ilorin, University of Ilorin Teaching Hospital, Ilorin, Kwara State;
SSH Yola, State Specialist Hospital, Yola, Adamawa State.
of training, 89.5% was formal or seminar based. These trainings
were given by non-government organisations, ministries of
health, hospitals and training institutions. While most of
the nurses were not satisfied with the EDs that are considered
not safe, few wished for redeployment to other departments
(table 5).
Most nurses were of the belief that the following attributes
will mitigate ED violence towards staff: availability (85%),
respectfulness (85%), supportive (53%) and responsiveness (68%).
DISCUSSION
The ED of any hospital attends to diverse clients with different
medical conditions whose common denominator is the acuteness of the condition necessitating immediate or urgent
attempts at remedy. Thus the emergency room offers a charged
atmosphere with pressure on the system and caregivers to
provide services which match the expectations of patients2
and/or their relations. This interface can be stretched, leading
to flaring of emotions, vituperations and physical assault on
Table 4 Average points for the rating on a scale of 0–5 for strategies for the prevention of ED violence in the centres of study
Centre of study
Strategies for the prevention of ED violence
UTH Ado
Mean
FMC Ido
Mean
FMC Owo
Mean
UITH Ilorin
Mean
FMC Lokoja
Mean
SSH Yola
Mean
Subtotal
Mean
Appropriate building design
Adequate provision of security systems and personnel
Use of trained security officers in the emergency room
Visible security inside and outside
Undress patients to reveal concealed weapons and disarm if necessary
Engagement of staff and local police in security planning
Adequate training of staff in violence recognition and handling
Use of patients’ liaisons in the waiting room
Flagging of violence-prone individuals
Adequate personnel that reduces the waiting time
Prompt reporting of cases to ensure review of policies
Prompt transfer of patients out of the ED
Blockage of unauthorised vehicle access to the ED
Minimised unguarded entrances; lock extraneous/exits at night
Secured sensitive areas with access control
0.50
1.83
3.33
3.82
1.83
0.58
0.58
0.67
1.83
0.36
2.55
1.50
2.33
2.08
2.25
2.73
3.23
2.62
3.15
2.00
1.92
2.31
1.82
2.25
3.08
3.62
3.42
3.25
2.85
2.85
2.31
2.00
2.38
2.54
1.00
0.64
1.75
1.31
1.21
2.40
2.25
260
2.73
2.75
1.81
2.42
2.55
2.50
2.17
2.00
2.17
2.92
2.82
2.92
3.80
3.64
3.92
2.92
2.55
2.82
2.50
1.67
1.11
1.44
1.00
1.33
1.00
0.56
2.13
2.00
1.88
1.89
3.17
4.44
2.89
1.33
1.22
1.33
0.11
0.44
1.50
1.00
1.00
1.50
2.00
2.38
2.13
1.00
0.63
0.57
1.97
2.14
2.31
2.33
1.40
1.33
1.70
1.39
1.99
2.30
2.76
2.65
2.62
2.59
2.26
0, not available or completely unsatisfactory; 5, readily available or very satisfactory.
ED, emergency department; FMC Ido, Federal Medical Centre, Ido-Ekiti, Ekiti State; FMC Lokoja, Federal Medical Centre, Lokoja, Kogi State; FMC Owo, Federal Medical Centre,
Owo, Ondo State; UTH Ado, University Teaching Hospital, Ado-Ekiti, Ekiti State; UITH Ilorin, University of Ilorin Teaching Hospital, Ilorin, Kwara State; SSH Yola, State Specialist
Hospital, Yola, Adamawa State.
760
Emerg Med J 2013;30:758–762. doi:10.1136/emermed-2012-201541
Original article
Table 5
Effects of violence on nurses in the ED
No. of people who have been direct victims of ED violence
Victim
Count
Not victim
N (%)
Count
Subtotal
N (%)
Count
N (%)
Decline in productivity as a result of violence witnessed
Decline
17
25.4
5
7.5
22
32.8
No decline
26
38.8
19
28.4
45
67.2
Subtotal
43
64.2
24
35.8
67
100.0
Suffering from loss of confidence in oneself resulting from ED violence
Suffered
10
15.2
0
0.0
10
15.2
Not suffered
32
48.5
24
36.4
56
84.8
Subtotal
42
63.6
24
36.4
66
100.0
Possibility of job satisfaction in the face of current state of violence in ED
Yes
5
7.6
5
7.6
10
15.2
No
38
57.6
18
27.3
56
84.8
Subtotal
43
65.2
23
34.8
66
100.0
Satisfaction with the state of ED with respect to issues of violence
Satisfied
2
3.2
3
4.8
5
7.9
Not satisfied
35
55.6
15
23.8
50
79.4
Indifferent
5
7.9
3
4.8
8
12.7
Subtotal
42
66.7
21
33.3
63
100.0
Thought of safety in the ED being guaranteed with the current state of the ED
Yes
6
9.4
5
7.8
11
17.2
No
28
43.8
9
14.1
37
57.8
Not sure
8
12.5
8
12.5
16
25.0
Subtotal
42
65.6
22
34.4
64
100.0
The chance of the hospital management doing enough to prevent ED
Yes
6
9.4
6
9.4
12
18.8
No
19
29.7
9
14.1
28
43.8
Not sure
17
26.6
7
10.9
24
37.5
Subtotal
42
65.6
22
34.4
64
100.0
Satisfaction with the way cases of violence witnessed were handled by the hospital
management
Satisfied
5
8.2
4
6.6
9
14.8
Not satisfied
35
57.4
16
26.2
51
83.6
Indifferent
1
1.6
0
0
1
1.6
Subtotal
41
67.2
20
32.8
61
100.0
Provision of appropriate support systems for staff who are victims of violent incidents
Yes
4
6.7
9
15.0
13
21.7
No
36
60.0
11
18.3
47
78.3
Subtotal
40
66.7
20
33.3
60
100.0
Frequency of those who, given the state of the ED, would wish to be redeployed to
another department if given the opportunity
Yes
16
25.4
12
19.0
28
44.4
No
17
27.0
7
11.1
24
38.1
Not sure
9
14.3
2
3.2
11
17.5
Subtotal
42
66.7
21
33.3
63
100.0
ED, emergency department.
caregivers by patients or their relations. The true incidence of
this violence is not known9 10; it is underreported in our environment as it is elsewhere.11 Moreover, several definitions of the
term exist,12 13 which may contribute to low reporting. The
National Institute for Occupational Safety defined workplace
violence as ‘an act of aggression directed towards persons at
work or on duty from offensive or threatening language to
homicide.14 This includes physical assault, verbal abuse, threat,
harassment or coercive behaviour causing physical or emotional
harm’.15 For this study five entities were highlighted in the definition of violence: witnessing verbal abuse on a colleague, witnessing physical threats or acts of intimidation against a
colleague, personal experience of verbal abuse or physical threat
Emerg Med J 2013;30:758–762. doi:10.1136/emermed-2012-201541
and actual assault on the respondent. Respondents all agree
that these entities constitute violence at their workplace.
The study spans three geopolitical zones in Nigeria, perhaps
making it fairly representative of a national trend. All centres
provide tertiary health services. None is officially designated a
trauma centre, but all are state recognised for trauma care services. The majority of respondents are female as the nursing
profession has female dominance in our environment. The
young and middle aged groups are affected as the respondents
are public servants whose retirement age has been statutorily
pegged at 60 years, or 35 years in service, whichever comes first.
Their work experience (mean professional experience and ED
experience of 13.2 years and5.3 years, respectively) does not
seem to confer any protection in experiencing workplace violence. We found that violence is targeted more towards nurses,
collaborating previous work.9–21 This may be due to more
contact time, poor interpersonal and communication skills and
nurse:patient ratio. Visitors ( patients’ friends and relatives)
tend to perpetrate the violence, unlike studies elsewhere in
which the patients were culpable.17 The assailants are principally male visitors, which is in keeping with cultural male
dominance and aggression. The majority of incidents occurred
in the evening, as was noted in previous work where evening/
night shifts alongside weekends ranked higher.10 13 17 For the
centres that experienced more violence in the mornings, it may
be due to arrival of more relatives after an overnight admission.
Several reasons have been given as probable causes of violence
in the ED.2 9–11 13 22 In our study we found the following
common to all centres: alcohol intoxication, substance abuse,
overcrowding in the ED, under-staffing, long waiting time,
little or no security measures in place, long stay in the ED
before transfer to appropriate wards or service, and spread of
gang or cultist conflict to the ED. This again is in consonance
with reports elsewhere.17 Use of weapons was not common in
our study (15.8%) and is comparable to findings by earlier
investigators.7 8 11 Not all institutions have adequate reporting
mechanisms; and they have weak control measures for prevention or containment of violence. At a national level, the health
industry has neither adopted nor implemented the policy of
‘zero tolerance’ to workplace violence. This contrasts with practice elsewhere.10 11 13 17 Loss of job satisfaction, self esteem and
decline in productivity were major effects of ED violence on
respondents. In some studies absenteeism, post-traumatic stress
disorder and even resignation were noted.9 10 22 To the
employer, loss of man-hours, damage of structure and equipment, insurance liability and workman compensation may
provide a staggering loss of revenue.21 The patient may suffer
stigmatisation and treatment bias.21 Preventive strategies have
been suggested, including advocacy, leadership training, staff
capacity building to recognise and avert potential stimulus for
violence, ED structural design to include security personnel,
and camera surveillance.13 23–25 A management policy of zero
tolerance to violence and adequate reporting mechanisms, and
sanctions where necessary could be helpful. Our respondents
recommend certain nurse attributes that may prevent occurrence of violence: availability, respectfulness, supportive care
and responsiveness to duties. The extent to which these qualities will prevent violence could be a subject for further studies.
CONCLUSION
Violence towards ED staff is common and nurses bear the brunt.
There is a need to make EDs safer for all users, or else we might
have to start wishing that our ED staff ‘come back home safe’
when they leave for work: like soldiers going to war!
761
Original article
Contributors All authors were involved in the formulation of the questionnaires used
and administered the questionnaires to the respondents in their respective hospitals.
KOO and ACE collated and analysed the data received. All authors were involved in
the preparation of the final draft of the manuscript.
An abstract was presented at the 10th World Conference on Injury Prevention and
Safety Promotion, London, UK and published in Injury Prevention (Inj Prev 2010;16
(Suppl 1):A26 (doi:10.1136/ip.2010.029215.0093).
Competing interests None.
11.
12.
13.
14.
Ethics approval Ethical review committees of each institution where the study was
conducted.
Provenance and peer review Not commissioned; externally peer reviewed.
15.
16.
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