Violence in the emergency department: an ethnographic study.

Background Violence in the emergency department (ED) is a significant problem and it is increasing. Several studies have shown that violence in the ED is more likely to occur within the first hour of a patient’s presentation. Therefore, it is possible that there are some indicators of violence observable during the initial nurse-patient/relative interaction at triage. Nevertheless the problem remains inadequately investigated as many incidents are not reported and most studies that have investigated this issue are descriptive in nature. Although these studies have provided important preliminary information, they fail to reveal the complexities of the problem, in particular the cultural aspects of violence which are crucial for the ED. Aims The main aims of this study were to explore the cultural aspects of violence in the ED and to determine the possible indicators of violence at triage. Methodology Contemporary ethnography based on interpretive and post-positive paradigms was adopted to frame the methodology of this study. Methods This study was carried out at a major metropolitan ED over three months. The data collection techniques included field observations, questionnaires and semi-structured interviews. The data analysis framework adopted for this study incorporated Spradley's (1980) and LeCompte and Schensul's (1999) approaches. Findings The study indicated that the cultural meanings of violence were complex and highly subjective with variations among nurses which in turn influenced their responses to violence (e.g. reporting or not reporting an incident). The cultural meanings were sometimes contradictory and confusing as violence could be seen as both a challenge and a threat or predictable and unpredictable. The same type of behaviour from one individual could be perceived as violent but not for another. Many nurses perceived that violence was unpredictable and inevitable but the study demonstrated that there were indicators of violence which could be used to predict and prevent the problem. Factors such as environment, conflicting messages regarding waiting time, and patients' expectations and needs played an important part in violence. Besides, there were immediate warning signs of violence such as the overt verbal (e.g. mumbling or shouting) and covert nonverbal signs (e.g. staring or agitation). This study showed that patients' behaviours for instance being unfriendly, not appreciative, inattentive and uncooperative were better predictors of violence in the ED than their traits or problems alone. However, nurse-patient/relative behaviours and the resulting reciprocal relationship were considered central in determining if violence would occur or be avoided. Nurses' efforts to establish rapport with patients was crucial in minimising violence and needed to occur early. There was usually a ‘turning point’ that provided an opportunity for the nurse to avoid violence. Nurses’ behaviours at the ‘turning point’ strongly influence the outcome. Nurses' awareness of their personal expectations, prejudices and ethnocentrisms were the pivotal points in preventing escalation of violence. Conclusion This study has provided a more comprehensive and sophisticated understanding of the cultural aspects of violence in the ED. While violence is a complex issue with many paradoxes, there are lessons to be learned. The study indicates that effective interpersonal empathetic communication has a significant role in reducing violence in the ED.Thesis (Ph.D.) -- University of Adelaide, School of Population Health and Clinical Practice, 200