The nature and extent of aggression in nurses' clinical settings

The concern raised in recent journal articles, reports and books about the level of aggression within nursing was the impetus for this study. Up until the last couple of decades the literature on aggression among health service institutions was sparse. The few nursing studies that are available on aggression deal with the extent and effect of patient aggression on nurses. But not all aggression is patient initiated. A few recent reports speak of horizontal violence, ie, the idea that staff can be aggressive towards each other. Understanding the extent of occupational aggression for nurses whether patient or colleague initiated is thus an imperative research agenda. A total of 299 nurses were asked for their views on the extent and nature of aggression at their work. Three main issues were addressed. First nurses' understanding of the term aggression was explored. Second, the nature and extent of aggression from patients and others to nurses and vice versa was determined. Third, causal relationships among variables were sought. Two contrasting methodologies were employed in the study. First, individual nurses (n = 29) from a variety of work settings were asked about their experiences of aggression in the clinical setting. This was essentially a qualitative study and it raised a number of important insights regarding nurses' understanding of the term aggression and the extent of the overall problem of aggression vis-a-vis patients, nurses and others. Because of the small sample size, it was felt unwise to extrapolate the findings to other similar contexts. Therefore,sa second study was conducted - Phase 2 - in which the views of 270 nurses were canvassed. As well as completing a questionnaire respondents were asked to view a short video of an encounter between two nurses. This enabled cause and effect relationships between hierarchy and blame placement to be determined through a survey-embedded experiment. Additionally, structural equation modelling was used to try an account for why aggression persists. The main findings can be summarised thus: First, nurses' understanding of the term "aggression" encompasses a range of behaviours and attitudes that can be conceptualized along three dimensions: physicalverbal; active-passive; and direct-indirect. In practical terms, this aggression was played out in such behaviours as rudeness, abusive remarks, undermining each other's ideas, refusing to help when needed and, more rarely, actual physical threat and assault. Much of the aggression can be seen as colleagues' failure to play by the relationship, rules of work. Second, the majority of respondents at Phase 1 indicated that aggression from colleagues is a major concern for them. Third, this view was largely confirmed in the lager sample at Phase 2. Taken together, colleagues, doctors, and non-nurse managers come under fire in many different work settings. Fourth, female and male nurses had similar views about the level of colleague aggression towards them. However, following colleague aggression, women were more concerned about aggression from patients' relatives and doctors, men had most trouble dealing with the aggression from their nurse managers. Fifth, nurses' reactions to aggression can be seen in terms of three main response patterns: a stress response, an anger response, and a reflective response. Sixth, there was support for thinking that aggression among nurses is situated within a culture that subscribes to the notion of a "task/time" imperative. Seventh, there was little support for the view that hierarchy influences blame placement preferences for deciding who should be blamed for an incident. However, the Level-2 nurse attracted more blame than either the Level-1 or the Level-3 grade for reacting aggressively towards a colleague who was late. It would appear that the Level-2 grade of nurse has a credibility gap vis-a-vis fellow colleagues. Eight, there was tentative support for the notion that aggression, once begun, may be self perpetuating. Ninth, overall, the results point to a worrying level of nurse-on-nurse aggression in the clinical setting