Background
Workplace violence (WPV) is an important occupational safety problem and has become a growing challenge for many governments worldwide. According to a survey conducted by the Institute of Labor, Occupational Safety and Health in Taiwan, employees in healthcare and the social services sector experience considerably more WPV than workers in other industries [1]. In Taiwan, roughly 50–80% of nurses have experienced verbal abuse, and 20–35% have suffered assaults [2‐5]. Studies have found that patient- and relative-instigated violence are the most common types of WPV experienced among nursing staff [5, 6]. WPV does harm to an individual both physically and psychologically, making the victim feel scared, angry, depressed or anxious [7, 8]. WPV also threatens one’s life and work performance [7‐9], and can lead to burnout, or an intention to change institutions, or leave the nursing profession altogether [10, 11].
As pointed out by the International Labour Office (ILO), International Council of Nurses (ICN), World Health Organization (WHO), and Public Services International (PSI) [12], WPV prevention starts with a risk assessment in the workplace. Occupational Safety and Health Administration (OSHA) [13] also proposed that worksite analysis plays a key factor in creating an effective WPV prevention plan. A worksite analysis consists of identifying potential hazards that could lead to violent incidents, as well as possible factors associated with violence hazards in the workplace. Previous research has indicated that a violent threat may be mitigated by the nursing personnel’s interaction with the patient and family. Examples of these scenarios include trying to negotiate patients’ or visitors’ acceptance of treatment procedures or discussing the decline of care or treatment with patients [14]. Scenarios are often compounded by patients spending a long time waiting at the clinic [3, 15, 16]. Nursing staff are also at greater risk of assault from high-risk, mentally unstable patients, such as patients with mental disorders [17‐19], those with drinking or substance abuse problems [16, 20, 21], and patients with dementia or Alzheimer’s [9, 20, 21].
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The National Institute for Health and Care Excellence (NICE) recommends using de-escalation to avoid imminent harm caused by hostility or violence [22]. De-escalation is a collective construct which uses communication, self-regulation, assessment, action, and safety maintenance to extinguish or reduce patient aggression and improve staff–patient relationships [23]. Academic studies into de-escalation strategies have primarily focused on imminent aggression [21, 24‐28] and the aftermath of violence [29, 30], without delving into the dynamics of de-escalation processes themselves. These studies have explored various proactive tactics including nurses maintaining distance from residents [31], adjusting emotional tension [32], observing patients’ body language or verbal cues [32], showing empathy for patients’ feelings [24], seeking assistance from security personnel [21, 32], and reporting the violent event to the head nurse after the experience [30]. Passive de-escalation strategies involve enduring or ignoring aggression [8, 26, 27, 30], apologizing or not resisting [29], withdrawing from perpetrators [25, 29], or swapping shifts [31], but nurses suppressing their emotions with these strategies can harm their mental well-being and work performance. Other nursing staff may resort to hostile methods like displaying aggressive attitudes or employing physical or chemical restraints, exacerbating conflicts [21, 27, 33].
This study aimed to identify conflict triggers and explored the protective capabilities that may help to effectively manage and mitigate such situations. We employed a qualitative approach to explore common conflict situations encountered by nursing staff in hospitals, particularly those that have the potential to escalate into violence.
Methods
Setting
We conducted the study at two regional teaching hospitals in New Taipei City, Taiwan – one public and one private. The two hospitals have 520 and 1,000 beds and approximately 400 and 550 nursing staff, respectively. We visited the hospital directors with the permission of the hospital administrators before conducting the study.
Sample
The target population for this study included nursing personnel from different departments/units and positions within the hospitals. This population consisted of approximately 50% Licensed Practical Nurses, 35% Registered Nurses, 15% Advanced Practice Registered Nurses, and 5% Nurse Managers. We used purposive sampling to target participants, specifically focusing on those who had encountered and dealt with violent situations involving patients and patients’ relatives, and who had at least five years of service in clinical settings. Acknowledging that purposive sampling may have introduced selection bias and that the sample may not have fully represented the broader population of nurses, we also employed a snowballing technique to broaden recruitment, using flyers delivered to the hospitals to reach potential participants. The sample size was determined by the principle of saturation. Initially, we recruited 24 healthcare workers but excluded nursing staff not working in clinical units. Ultimately, we conducted interviews with 21 nurses from 2015 to 2016.
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Instruments
A guide was used in the interview process to ensure that all topics were covered, as follows:
1.
As a healthcare worker, what kind of work-related conflicts or violent scenarios have you encountered?
2.
What factors contributed to these violent situations?
3.
Could you briefly describe the process when a conflict or violent episode occurred?
4.
How did you take action to prevent or manage these conflicts or violent situations?
Data collection
Before the interviews, participants were informed that participation was voluntary and that they could withdraw from the study at any time without needing to give any reasons and without concern for any negative consequences. We obtained signed informed consent forms from each interviewee. Interviews were jointly conducted by two researchers – Fu-Li Chen, a senior Professor in the field of Health Behavioral Sciences, led the interviews, and either Chia-Chi Liu or Ting-Ya Kuo, both research assistants, made field notes during the process. None of the participants had any relationship with the researchers. Each face-to-face interview was recorded (with consent), took around 50–60 min and was conducted in the hospital’s meeting room.
Data analysis
Figure 1 shows the implementation process. Qualitative content analysis was used to create categories in the following phases, as recommended by Graneheim and Lundman [34]. To gain a full understanding of the interview content before coding, we carefully and comprehensively read all the transcripts. Then, we extracted information regarding common conflict situations that could lead to WPV and descriptions of helpful protective capabilities. During this process, meaning units were identified and condensed. Next, the condensed meaning units were labeled with a list of initial codes. Then, the same codes were grouped to form sub-categories, which later formed categories. We re-examined the texts to ensure that all the interview material was covered by the categories. Lastly, themes were developed by grouping several categories together.
Fig. 1
The research design and implementation process
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Trustworthiness
Several strategies were employed to ensure trustworthiness. First, we shared a verbatim script with each research participant and confirmed that what they expressed was correct. Then, to enhance credibility, the lead researchers/authors (FL & TA) conducted a data analysis. When a disagreement arose over how to categorize codes, we held a meeting with all authors to reach a consensus. Every phase of analysis was tracked and recorded so that the process of analysis could be clearly presented. In addition, to enhance dependability of the study, an external auditor (a head nurse) reviewed the results of the data analysis to ensure that it was a true reflection of participants’ data.
Researchers’ reflexivity
The primary researchers in this study have conducted research in or had practical experience with WPV that might have influenced the research. To promote self-reflection and awareness of our biases, we used reflective diaries to record personal biases and reflections, to ensure transparency and attempt to reduce potential bias. Our insights and reflections on what we learned during the interviews gradually changed our perspectives and positions. We gradually moved from ‘outsider’ to ‘insider’ which forced us to reconsider some of our biases.
Ethical considerations
The study was approved by the Institutional Review Board of Fu Jen Catholic University (No: C103076) and the Research Ethics Review Committee of the New Taipei City Hospital (No:104004-E). Written informed consent was obtained from all participants. For all data (including field notes, recordings, and transcripts), names were separated from codes to maintain the participants’ confidentiality. The recordings and transcripts have been stored on a locked computer by the principal investigator.
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Results
Table 1 presents the background information of all participants. All were female; four were supervisors and 17 were clinical nurses. These respondents served in a range of units: medical wards, surgical wards, psychiatric wards, outpatient clinics, community care centers, recovery rooms, operating rooms, ERs, and intensive care units. On average, they had completed 14 years of service.
Table 1
Basic participants’ information
Participant ID | Gender | Age | Current work unit | Position | Years in nursing |
|---|---|---|---|---|---|
No.1 | female | 42 | Community Care Center | Nurse | 20 |
No.2 | female | 36 | Anesthesiology Department | Head nurse | 12 |
No.3 | female | 43 | Anesthesiology Department/ Postoperative Intensive Care Unit | Nurse | 8 |
No.4 | female | 44 | Emergency Room | Nurse | 11 |
No.5 | female | 35 | Emergency Room | Nurse | 8 |
No.6 | female | 39 | Surgical Ward | Nurse | 14 |
No.7 | female | 35 | Operating Room | Nurse | 15 |
No.8 | female | 38 | Anesthesiology Department/ Postoperative Intensive Care Unit | Nurse | 12 |
No.9 | female | 35 | Outpatient Clinic | Nurse | 6 |
No.10 | female | 55 | Outpatient Clinic | Nurse | 15 |
No.11 | female | 42 | Outpatient Clinic | Nurse | 12 |
No.12 | female | 33 | Emergency Room | Nurse | 13 |
No.13 | female | 39 | Outpatient Clinic | Nurse | 18 |
No.14 | female | 39 | Emergency Room | Nurse | 18 |
No.15 | female | 40 | Anesthesiology Department/ Postoperative Intensive Care Unit | Nurse | 6 |
No.16 | female | 44 | Community Care Center | Nurse | 13 |
No.17 | female | 40 | Medical Ward | Nurse | 15 |
No.18 | female | 40 | Intensive Care Unit | Head nurse | 12 |
No.19 | female | N/A | Psychiatry Ward | Head nurse | 35 |
No.20 | female | N/A | Nursing Department | Nursing Supervisor | 23 |
No.21 | female | N/A | Emergency Room | nurse | 13 |
To identify strategies to prevent or reduce conflict, we first summarized one overarching theme of potential violent conflict scenarios and then developed four themes on the strategies to prevent or de-escalate conflict based on these scenarios.
Theme: potential violent conflict scenarios
The theme potential violent conflict scenarios was comprised of four categories as described in Table 2:1) potential for violence resulting from hostile reactions to unreasonable requests from patients/family, 2) caring for patients with mental and behavioral problems, 3) patients waiting a long time for medical consultation, and 4) proximity of physical distance when caring for patients.
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Table 2
Potential violent conflict scenarios in the medical setting
Theme | Category | Sub-category | Codes (participants’ ID) |
|---|---|---|---|
Potential violent conflict scenarios | 1.Potential for violence resulting from hostile reactions to unreasonable requests from patients/family | Non-medical care requirements | Request nurse to make powdered milk (No.1), pull up the blanket for the patient or turn off air conditioning (No.4), change the bed sheets (No.6) |
Unreasonable medical needs | Request nurse to explain the patient’s medical state (No.19), get examination report immediately (No.9), request for immediate hospitalization (No.21, No.5) | ||
Make special arrangement | Asked to cut the line to see a doctor (No.7, No.9), asked to go ahead to see a doctor (No.7, No.8, No.10, No.11) | ||
2.Caring for patients with mental and behavioral problems | Care for intoxicated patients | Intoxicated patients resisting measurement of vital signs (No.12, No.5), treating wounds (No.20), lying on floor resisting movement (No.5, No.13, No,14), mumbling nonsense (No.21), patient restrained from drinking on ward (No.17) | |
Care for drug-induced psychosis and psychiatric patients | Appearing to have drug-induced or psychosis symptoms (No.19, No.12), psychiatric patients with behavioral problems (No.4, No.19, No.2, No.3) | ||
3.Patients waiting a long time for medical consultation | Long wait times for outpatient clinic | Patients waiting impatiently for delayed consultation by doctors (No.7) or for examination (No.11), long wait times at psychiatric outpatient clinic (No.10) | |
Long wait times for emergency care | Patients complain of long wait times as they think they are an emergency (No.21, No.5, No.16) | ||
4.Proximity of physical distance when caring for patients | Nursing staff physically close to the patients | Close contact when measuring blood pressure (No.21) or room visit on ward (No.19), proximity to caring for patient in ER (No.14) |
Potential for violence resulting from hostile reactions to unreasonable requests from patients/family
Hostility towards nurses can arise from denying patients/family unreasonable non-medical care requests like food preparation or grooming. For instance, a nurse faced violent conflict after declining such a request:
The “red light for patient needs” is often pressed at night [but it was] the family member [who had] pressed the patient’s red-light button and requested personal housekeeping service. [They said] Oh…he’s sleeping, don’t disturb him, you [nurse] come and cover him or turn off the air conditioner. [No.4]
Respondents noted that patients/families frequently make unreasonable procedural demands during medical care, like asking nurses for immediate explanations of their condition or test results. Failure to meet these needs has led to verbal or physical violence:
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In the past week, a family asked about the patient’s condition, but we prefer the doctor to do it. But he felt that the nursing staff’s attitude was not good, so he slammed his hand on the table on the spot. [No.19]
I explained to the patient that this visit was a make-up test and wouldn’t see the report today, then she threatened me saying that she must see the report today no matter what, with a loud roar for at least 5–6 min. [No.9]
Respondents also indicated that patients have requested immediate visitation with the doctor after missing their place in the queue, with verbal confrontations arising as a consequence:
Outpatient clinics often have patients who want to jump the queue for a consultation, or the patient number is very far back and argues to be seen first, leading to conflicts between patients and nurses. [No.7]
Caring for patients with mental and behavioral problems
Nursing staff confront potential conflict situations when dealing with patients who have mental and behavioral problems (e.g., intoxicated, drug-induced psychosis, psychiatric patients), especially in the emergency room or psychiatric ward. Patients often verbally threaten caregivers or physically attack caregivers without warning, due to their condition:
We were going to draw his blood, and he suddenly jumped down and ran to the front of the nursing station, and started to speak more and more aggressively, and kept making verbal threats and slapping the table. [No.12]
Patients waiting a long time for their medical consultation
Long wait times are occasionally a trigger for emotionally unstable patients to verbally abuse nursing staff. Many respondents pointed out that long wait times at outpatient clinics or emergency care and patients’ lack of understanding of administrative procedures are major causes of WPV:
In the obstetrics and gynecology outpatient clinic, the doctor had to leave the clinic to deliver a baby, when a disturbed pregnant woman in the clinic banged on the door and complained loudly for a long time! [No.7]
A patient comes to emergency room for a cold. Although he is in a hurry, we have to deal with emergency first aid immediately. We put him to the back of the line, and he directly threatened to say: I came first, why others than I still come late he can see first. [No.21]
Proximity of physical distance when caring for patients
Respondents pointed out that when performing medical tasks that require close physical contact – for example, measuring blood pressure and listening to patients – they often face physical harassment from patients:
I wanted to measure his blood pressure and his hands came up close to me. I pushed away his hands but was very nervous and uncomfortable. [No.21]
A patient physically harassed and attempted to sexually assault a nurse while she was in the psychiatry ward… [No.19].
Protective capabilities against potential violent conflict scenarios
Protective capabilities against violent conflict scenarios were sorted into four themes, as shown in Table 3; Fig. 2. Each theme was sub-categorized as a method of preventing or reducing violent situation responses. The first category includes interpersonal communication capabilities, such as negotiation, soothing emotions, and empathy. The second category includes problem-solving abilities, such as distancing oneself from the offender, taking safety precautions, explaining the situation, leaving the room or area, and seeking colleagues’ support. Following is a description of each theme.
Table 3
Protective capabilities in violent conflict scenarios
Theme | Category | Sub-category | Codes (participants’ ID) |
|---|---|---|---|
1.Protective capabilities to face unreasonable requests from patients | Interpersonal communication skills | Negotiation | Discussions with family members about what they can do to care for the patient (No.4), asked relatives to help with daily care first, and then told that daily care is not professional care by caregivers (No.1) |
Soothe emotions | Sooth patients’ emotions (No.9), calm patients down (No.7) | ||
Problem-solving skills | Explain the situation | Explain the outpatient process (No.7, No.9) | |
Seek support | Ask the supervisor on duty or physician for support (No.5, No.19) | ||
2.Protective skills for caring for patients with mental and behavioral problems | Interpersonal communication skills | Negotiation | Negotiate alternatives for patients’ needs (No.19) |
Problem-solving skills | Safe action | Stay two steps away from the patients (No. 20), put hands in front of the chest (No. 14), take a step back (No. 19) | |
Seek support | Call the police, notify the supervisor (No. 5), call the security guard (No.19, No.2), ask for assistance from other nursing staff (No. 3) | ||
3.Protective capabilities for dealing with patients waiting a long time for medical consultation | Interpersonal communication skills | Negotiation | Suggest patients be transferred to a second outpatient appointment (No. 7) |
Soothe emotions | Calm patients down (No. 7) | ||
Empathy | Listen to the family or patients’ complaints (No. 21) | ||
Problem-solving skills | Seek support | Call the head of nursing (No. 7), signal the hospital guard with eyes for help (No. 21), ask for police assistance (No. 21) | |
Explain the situation | Explain the emergency room procedure (No. 21) | ||
Leave the scene | Leave the aggressive patient temporarily (No.5) | ||
4.Protective skills to cope with close contact patient care | Problem-solving skills | Safe action | Take a step back (No.21) |
Seek support | Ask for help from the nursing staff (No.19) |
Fig. 2
Protective capabilities in violent conflict scenarios
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Theme1. Protective capabilities to face unreasonable requests from patients
Respondents indicated that when faced with unreasonable requests from patients/families, they often use interpersonal communication skills, including negotiation, being reassuring and seeking support, to prevent or reduce the risk of violence. For example, patients/families often ask nursing staff to perform non-medical care tasks. In this case, to avoid direct refusal and induce conflict, interviewees indicated that they first explain to the patient the limitations of the nursing staff, then discuss with the families how they can assist with these non-medical care tasks:
I didn’t refuse directly, I told him: there is no such manpower at the moment, so could you help us to help serve your elder. Later when the family member calmed down, I told him: your request is too much, it’s over the medical care. [No.1]
Another situation is when a patient engages in verbal threats and unreasonable demands to see doctors or test reports immediately. The interviewees described how they used communication skills and problem-solving capabilities to avoid a violent incident with a patient:
She threatened me that demanding to see the report immediately no matter what, and she ranted loudly for at least 5–6 min. I asked her to go outside and to soothe her emotions a little bit. [No.9]
I’ve often had patients who wanted to jump the queue to see the doctor. One patient’s number was very high but he was arguing to see the doctor first, I would calm him down and then explain to him. [No.7]
Respondents also pointed out situations where they couldn’t satisfy a patient’s family’s request to explain the patient’s clinical condition, resulting in a verbal threat or physically aggressive behavior. In this situation, clinical nurses usually ask the supervisor on duty or the physician for support to just walk away:
The first thing you should do is to ask the supervisor on duty to come down to help deal with the situation, but it takes him away from his duties for about 30–40 min. [No.5]
Theme 2. Protective skills for caring for patients with mental and behavioral problems
The nursing staff said that the clinical care of alcoholic or psychiatric patients required safety actions to prevent violence, such as maintaining a safe distance to avoid close contact or placing hands over the chest to protect themselves. When an alcoholic or psychiatric patient attacks, the nurse can immediately shield or swing away:
Talking to a drunk patient I’m always two steps away from the person, that is, not very close to the patient. [No.20]
I used to put my hand here (in front of my chest) to block or wave it away as soon as he made a sudden movement. [No.14]
Occasionally, direct violence occurs in clinical settings. When physical violence does occur without warning, nursing staff state that they first call the police and then inform their supervisors:
We will avoid some offensive behaviors that we can foresee, however, some situations are unpredictable, and we must call the police first and then notify the supervisor second. [No.5]
Theme 3. Protective capabilities for dealing with patients who have to wait a long time for medical consultation
Nursing staff indicated that when an outpatient has a long wait time, occasionally they become angry and expressive, even verbally abusive. In this case, the nursing staff try to placate the patient and discuss alternative options with the outpatient staff (e.g., suggest that the patient be transferred to a second outpatient appointment), and then seek support from the chief nursing officer or supervisor:
I told her that the doctor was delivering a baby and unavailable and offered her to switch to another doctor or something, but she still cursed and cursed and cursed …. I told her I was sorry he had to deliver the baby, but I had to calm her down… Otherwise, please wait for a while…the doctor will return to the clinic after delivering the baby…when there is really no way to deal with the situation, it is necessary to call the head of nursing or supervise. [No.7]
Another situation that occurs in the emergency room relates to the triage process. The interviewees said that non-serious emergency patients would often appear angry and impatient when they had to wait. Nurses listened to the patient’s needs first and then explained to the patient the emergency room procedure and their diagnosis, often reducing the aggressive/violent behavior.
I spent time listening to the family or patient complaining, and then explain to that because your injury level is about grade 4 or 5, you must wait. Because the patient who is treated first is grade 1, meaning they have immediate life-threatening injuries, so we must help them first. [No.21]
However, if a patient/family member becomes impatient and starts uttering verbal threats or abuse, the interviewees said that they signal to the hospital guard with their eyes, asking him for support or to press the anti-violence alarm linked to the local police station, requesting immediate assistance to help deal with the situation:
If the violent behavior of the other party has affected our medical treatment, we will press the police link and ask the police to help us deal with it. [No.21]
Respondents also indicated that they would leave the scene and stay away from the aggressive patient to avoid more misunderstandings that could anger the patient and produce serious violence, or they would exchange jobs with other nursing staff to avoid further contact with the aggressive patient:
It may be better to leave the scene temporarily and not let the patient become more and more angry. Otherwise, we usually switch to a substitute nurse (often male) and you don’t contact the patient or the family again. [No.5]
Theme 4. Protective skills to cope with close contact patient care
When clinical nursing staff perform routine medical tasks and are in close contact with patients, they usually stay alert. If they perceive any sort of threat, they immediately step back to maintain a safe distance from patients:
When I want to measure his blood pressure, his hand comes up and I step back, so he doesn’t touch me. [No.21]
Respondents also pointed out that when a patient physically harassed and attempted to sexually assault a nursing staff member, they asked for help from a colleague:
A patient physically harassed and attempted to sexually assault the nurse while she was in the psychiatry ward. Fortunately, the other patient witnessed it and then asked for help from the nursing staff at the nursing station to de-escalate the situation. [No.19]
Discussion
This study found that good communication and problem-solving skills serve to de-escalate the potential for violent responses. These finding are supported by Dafny and Muller’s similar study [35]. Regarding unreasonable requests from patients and relatives, three common potential conflict scenarios were identified: (1) when a nurse refuses to perform non-medical professional care demanded by a patient or family member, (2) when a patient or relative demands medical care or information that can only be provided by a doctor, and (3) when a patient demands special treatment (e.g., going directly to the head of the queue). Few studies have identified the relationship between these potential conflict contexts and individual protective capabilities [36]. To fill this gap, this study has summarized de-escalatory ways to prevent potential conflicts. For example, nurses can explain to patients and their families and help them understand the duties and responsibilities of nurses and then negotiate with them to reach consensus on a mutually-acceptable solution, or nurses may request that the doctor explains the patient’s medical condition to the family. These are only a couple of examples from a list of skills that may serve as a useful reference for clinical nurses in practice.
We found that nurses who take care of high-risk patients, such as those suffering from alcohol or substance abuse, or those with mental disorders, were especially susceptible to violent assaults. This confirms the results of previous research into WPV in the healthcare sector [16‐20, 37]. To de-escalate these potential conflicts, we have derived several protective steps, beginning with identifying high-risk potential patients and staying alert. Once a high-risk patient has been identified, nurses can maintain a safe distance and, if necessary, use protective measures such as placing their hands over their chest to counter sudden attacks, or using a safety whistle to alert colleagues during an assault. Several other studies have suggested similar strategies: hospital nurses and nursing home caregivers who remain alert, identify risk factors early, and keep a safe distance when attending to high-risk patients can avoid becoming victims of WPV [25, 31]. Our results also illustrate that a violent conflict is beyond a paid security guard’s ability to manage. The most effective response is to immediately seek police intervention, which corresponds with the research results of Tan et al. [32]. These de-escalation skills can be enhanced via interactive (i.e., scenario-based) training for nursing personnel.
Long wait times in the emergency room can contribute to violence, often exacerbated by poor communication, lack of managerial involvement, or ineffective security interventions [15, 16, 27, 38]. Several studies have shown that many nurses attempt to just endure or ignore a violent situation [27, 30]. This study also found that some respondents reacted passively or defensively to patients frustrated by long wait times, which could escalate conflicts because in both cases there is ineffective communication. The de-escalation capabilities listed in our study include soothing a patient and helping them to calm down, listening to the patient and family and empathizing with them, explaining the triage or outpatient care procedures, and negotiating with the patient and family to find an alternative solution to long wait times. The results also partially dovetail with the findings of Berring et al. (2016) who reported that de-escalation of violence in mental health care consisted of the following actions: listening to and sympathizing with patients’ worries and fears and engaging in creative social interactions [24]. Also similar to previous studies [30, 37], our results found that if a patient’s dissatisfaction cannot be easily managed, nurses should seek help from a head nurse, security guard, or the police.
When nurses provide routine care, like checking blood pressure or performing examinations, they often find themselves in close interaction with patients, making them vulnerable to physical harassment. Studies have highlighted sexual harassment as a prevalent form of violence experienced by female nursing staff [39‐41]. Failing to address such harassment or ignoring it can have detrimental effects on nurses’ physical health, mental well-being, and job performance [31]. A few participants in our study reported using an unyielding approach to handle sexual harassment which most often led to an escalation of the confrontation. However, some respondents suggested that a more effective preventive strategy is to remain alert, maintain a safe distance, or seek help from a supervisor or colleagues. This aligns with the findings of Zeighami et al. [31] and Adams et al. [42], who categorized nurses’ responses to sexual harassment. Among these, one category – “show an overly aggressive attitude” – was considered an excessive response, and another category – “keeping a safe distance, asking for help from a manager or colleagues, and discussing solutions like changing wards or work shifts”–was a preferred response.
Although the data for this study was collected prior to the COVID-19 epidemic, the first author is a senior clinical nurse and has served as the Deputy Superintendent at one of the hospitals participating in this study. According to her first-hand observations and experiences, the findings reflect nurses’ present experiences at work. Therefore, the protective capabilities identified in the present study are applicable to violence prevention training and practice for the nursing staff in the healthcare settings.
Limitations
This study has several limitations that should be considered. First, all participants were recruited from two regional hospitals in northern Taiwan. This limits the generalizability of the results to other medical settings, such as community nursing homes, or to other regions of Taiwan, including central, southern, or eastern areas. Second, the protective capabilities identified were based on participants’ recall of their responses to WPV from several years ago, which could introduce potential recall bias due to unclear or incomplete memories. Third, the small sample size of 21 purposively selected nurses may limit the representativeness of the findings because the participants may not represent the broader population of nurses. Finally, the study summarized protective capabilities to help both prevent violence and decrease conflicts, which may have blurred the distinctions between these two areas. These limitations suggest that the findings should be interpreted with caution and that further studies should be conducted with more diverse samples.
Conclusions
Nursing staff encounter all kinds of potential violence in the workplace and preventive and de-escalatory capabilities come in a variety of forms. Multiple protective capabilities can be used in a conflict scenario. Interpersonal communication capabilities consist of negotiation and empathy, and problem-solving skills proffer solutions such as leaving the conflict, taking action to ensure personal safety, explaining the situation to the patient, or seeking help. These protective capabilities can be used as a reference for clinical nurses in practice. Additionally, institutions and nursing supervisors play crucial roles in preventing workplace violence by providing in-service training and fostering a safe working environment.
Acknowledgements
We would like to express our gratitude to Mrs. Chia-Chi Liu and Mrs. Tz-Jung Pan for their assistance in conducting interviews and for serving as auditors in reviewing the results.
Declarations
Ethics approval and consent to participate
The study protocol was approved by the Institutional Review Board of Fu Jen Catholic University (No: C103076) and Research Ethics Review Committee of the New Taipei City Hospital (No:104004-E). Prior to data collection, participants were provided with comprehensive written and verbal information about the study. The participants had the right to withdraw from the study at any time. Each participant consented by signing an informed consent form.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
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