Introduction

Inadequate care, poorly performed medical services, and staff shortages can cause aggression and compromise the safety of patients and medical personnel [1]. Factors that increase a patient’s risk of aggression may include low social status, stress, frustration, witnessing aggressive behaviour of other patients, inability to control one’s emotions, young age, and male gender [1]. The European Commission defines aggression as an incident in which a person is attacked, bullied, and insulted in the workplace. This has a major impact on the well-being, health, and safety of medical professionals [2].

Working during short-staffed periods such as the night shifts and the weekends leads to nurses being more likely to be exposed to aggressive behaviours of the patients [3, 4]. This is related to their regular contact with patient-clients [5].

The purpose of this study was to investigate the causes and manifestations of patients’ aggression in the opinion of nurses.

Material and methods

To achieve the purpose of the study, the method of diagnostic survey, interview, and statistical methods (descriptive statistics methods, multivariate analysis, arithmetic mean) were adopted.

The study used a point-biserial correlation coefficient, which is used to measure the relationship between a dichotomous feature (indicating individual forms of aggression) and numerical measures. The Mann-Whitney test was used for the comparison of two groups to analyse the differences between the selected factors and the occurrence of aggressive behaviour. The statistical significance level of p = 0.05 was assumed. STATISTICA software was used for statistical analysis.

The research tools included the Author’s Survey Questionnaire for Nurses and the Courtauld Emotional Control Scale (CECS). The Author’s Survey Questionnaire for Nurses consists of 23 questions about the nurse’s attitude toward the patient, sociodemographic factors, assessment of the effectiveness of the undertaken actions, type of services, nurse’s reaction to the patient’s complaints, and the patient’s behaviour. CECS contains 21 statements that allow one to obtain an overall emotion control score. It includes three subscales, each consisting of seven statements regarding the way anxiety, depression, and anger are manifested.

The study group consisted of 300 nurses working at the Clinical Provincial Hospital No. 1 in Rzeszów (CPH). The study was conducted between May and December 2019. Nurses from both the non-surgical and surgical departments participated in the study. The following number of nurses were surveyed with the division into specific departments: Neurology 18 (6.0%), Dermatology 13 (4.3%), Gastroenterology 31 (10.3%), Laryngology 22 (7.3%), Ophthalmology 20 (6.7%), Urology 24 (8.0%), Oncology 24 (8.0%), Radiotherapy 19 (6.3%), Nephrology 31 (10.3%), Haematology 26 (8.7%), Surgery 52 (17.3%), Gynaecological Oncology 13 (4.3%), Dialysis 7 (2.3%). The youngest nurses indicated that they were under 30 years old, and the oldest were over 60 years old. Nurses with work experience of 1 to 5 years (21.7%) represented the largest group of surveyed participants. In addition, a fairly large group composed of nurses with 26–30 years of work experience (16.3%) as well as with over 30 years of work experience (15%).

Figure 1. Aggressive behaviours identified by the nurses. The percentages may not add up to 100%, as respondents could select any number of response options

The study was approved on February 14, 2019, by the Bioethics Committee at the University of Rzeszów (study approval reference number 27/02/2019).

Results

The views of the nurses about the incidence of aggression in hospitals are shown in Figure 1. For most of the surveyed nurses (n = 277; 92.6%), aggression was primarily associated with the use of vulgar language (Fig. 1).

The subsequent questions were related to direct exposure to aggression among the surveyed nurses. In their work, nurses most often experienced vulgarity (one in five) and yelling (one in six). On the other hand, forms of physical aggression such as choking, kicking, and spitting were the least frequently reported (Tab. 1).

According to the respondents, the patient behaviours that threaten nurses’ safety the most are physical violence, followed by verbal violence (Fig. 2).

Figure 2. Patients’ behaviours that diminish the sense of security among nurses. The percentages may not add up to 100%, as respondents could select any number of response options

In addition, the correlation between patient behaviours that diminish the sense of security and CECS scores was analysed. Considering that questions posed to respondents allowed multiple choice, a point biserial correlation coefficient was used for the analysis to determine the correlation between the dichotomous variable (indicating different forms of aggression) and numerical measures. For most of the comparisons made, no correlations were found; the exception being very weak, negative correlations between the suppression of depression and verbal aggression, humiliation, and bullying as forms of patients’ aggression experienced at work. As seen in Table 2, the minus sign next to the correlation coefficient indicates that respondents faced with these forms of aggression have lower levels of depression suppression. The lower the suppression of emotions, the more adequate the perception of aggressive situations — a person knows what he or she is feeling, shows, and controls the emotions on an ongoing basis.

Exposure of surveyed nurses to patients’ aggression

According to 219 (73.0%) respondents, the most common reason for patient aggression was a long waiting time for medical services. According to 35 (11.7%) nurses, this type of behaviour was associated with inappropriate behaviour by healthcare professionals, making it the least often indicated reason (Fig. 3).

Figure 3. The most common reasons for patients’ aggressive behaviour. The percentages may not add up to 100%, as respondents could select any number of response options

When confronted with aggressive behaviour, more than half of the surveyed nurses indicated that they tried to talk to the patient. Respondents also sought to ensure their own safety and the safety of other patients (Fig. 4).

Figure 4. Nurses’ interventions when confronted with aggressive patients. The percentages may not add up to 100%, as respondents could select any number of response options

Discussion

Aggressive behaviour toward medical staff is increasingly common and exerts a disruptive effect on the entire medical personnel. It contributes to professional burnout, sickness-related absenteeism, fear for life and health, deterioration of interpersonal relationships, worse performance at work, lack of job satisfaction, and experiencing negative emotions toward patients as well as toward the healthcare system. A negative patient attitude leads to a higher incidence of medical errors [6]. In a study conducted in South Africa, Ward et al. showed that the problem of aggression occurs in the immediate environment, and may involve health impairment risks. Also, there is a clear upward trend in the occurrence of psychological as well as physical aggression toward healthcare professionals [7].

Poland has implemented a system for monitoring aggressive behaviours in healthcare, i.e. the System for Monitoring Aggression in Healthcare (MAWOZ). The system was introduced on October 1, 2010, by the Supreme Chamber of Nurses and Midwives and the Supreme Medical Chamber. In 2016 a total of 41 cases were reported, which compared to 2015 data shows that the surge in such behaviour almost doubled. By September 4, 2017, 17 incidents of insult, vandalism, physical aggression, threats, slander, and blackmail have been reported. Reasons for aggressive behaviour reported by medical staff included refusal to comply with unreasonable requests, excessive waiting time for medical services, and dissatisfaction with their quality [8]. Nurses often experience aggressive patient behaviour in their work [9]. According to Gascon et al. [10], nurses believe that patients’ aggression is inherent in their work and cannot always be prevented. Experiencing aggressive behaviour can lead to professional burnout, feelings of inferiority, leaving the profession, and anger. Augustynowicz et al. [11] pointed out that nurses spend the most time with patients and have the most frequent contact with them. At the same time, patients are more likely to exhibit aggressive behaviour toward this specific professional group. In a study by Krajewska-Kułak et al. [12], 96% of nurses, 86% of midwives, and 90% of doctors experienced aggressive patient behaviour. Hospital medical staff is exposed to it even several times per week. In a study conducted by Grudzień et al. [13], 99.1% of respondents experienced aggressive patient behaviour in their work (nurses — 46.2%, doctors — 50%, paramedics — 66.7%). The most common actions reported include vulgarity, treating and speaking disrespectfully, raising voice, and verbal aggression. Physical aggression directed at medical personnel was reported by 25.2% of the respondents. When it comes to frequency, 33.9% said that they experienced occasional aggressive behaviour, 16.6 % — several times a month, and 48.7 % of respondents said that they were exposed to patients’ aggression several times a month or at least once a month.

In the present study, nurses reported the occurrence of physical aggression (choking, kicking, spitting) least often. When confronted with aggressive behaviour, 67.3% of nurses tried to talk to the patient, and 54.3% additionally tried to ensure their own safety and that of other patients. Nurses reported that their sense of security is diminished by physical and verbal aggression.

Grudzień et al. [13] showed that medical staff in emergency departments (41.2%), non-surgical departments (54.8%), and psychiatric departments (68.2%) experience aggression from patients. Between 70 and 84% of nurses had contact with an aggressive patient [13]. Half of the nurses reported that they experienced various forms of aggression, from either the patient or the patient’s family every day while at work. Interesting results were obtained by Quine et al. who found that supervisors and colleagues also displayed aggression toward nursing personnel, as indicated by 44% of the surveyed nurses [14]. The present study showed that nurses most often experienced vulgarity (one in five) and yelling (one in six). According to 73.0% of respondents, the most common reason for patient aggression was a long waiting time for medical services. According to 11.7% of nurses, this type of behaviour was associated with inappropriate behaviour by healthcare professionals, making it the least often indicated reason. It appears that an insufficient number of nurses on duty might contribute to the occurrence of such behaviours, as this situation prolongs the provision of medical services; increased nurse staffing could significantly reduce the incidence of aggressive behaviour among hospitalized patients. Jones et al. found that verbal aggression was one of the most frequently displayed forms of aggressive behaviour in dialysis patients [15, 16]. Similar conclusions were drawn by Lickiewicz et al. [17] who clearly showed the scale of the verbal aggression phenomenon. Out of 302 respondents, 273 cases of aggression were reported. A study by Rudnicka-Drożak et al. found that 77% of paramedics and 23% of nurses experienced aggression from patients: respondents were exposed to self-aggression — 25%, physical aggression — 34%, and verbal aggression — 41% [18]. Jankowiak et al. observed that verbal aggression was experienced by 40% of surveyed nurses [19]. Data from the American Nurses Association revealed that threats and verbal aggression were experienced by 57% of working nurses [20]. According to Kowalczuk et al., patients most often expressed verbal aggression toward doctors (80%) as well as toward midwives and nurses (75–80%) [21]. In the current survey, 92.6% of nurses indicated that aggressive behaviour was most associated with the use of vulgar language or humiliation (76%). Most often, physical aggression was associated with a reduced sense of security, according to 84.3% of respondents. The use of the Author’s Survey Questionnaire for Nurses and the Courtauld Emotional Control Scale CECS allowed the authors to notice that less suppression of emotions (anger, depression, anxiety) enables a more adequate perception of aggressive behaviours. Therefore, the obtained results can be the basis for building fundamental principles of cooperation in the patient-nurse relationship, as well as strengthening mutual understanding and appropriate relationships. Markiewicz et al. found that for 70% of nurses, the greatest psychological burden was the insecurity and state of danger that resulted from contact with verbally and physically agitated patients [22, 23].

Reporting the aggressive behaviour of patients is not equivalent to only taking action in the form of punishment for the aggressive patient. It is worth emphasizing that in the event of aggression on the part of the patient, e.g. hitting, yanking, or using vulgar language toward medical staff, claims under civil and criminal law may be pursued [11]. Unfortunately, not all incidents of patients’ aggressive behaviour are reported [22]. The obtained results of the present study concerning causes and manifestations of patients’ aggression in the opinion of nurses are thought-provoking and invite a closer examination of this problem. Comprehensive high-level nursing care in a hospital, improving the qualifications of healthcare workers, and appropriate behaviour of medical staff all affect the positive assessment of a given unit and thus attract other clients (patients) to use medical services.

The conducted research showed that nurses often encounter aggression from patients. It is, therefore, necessary to take measures to prevent such behaviour from occurring. Professional and comprehensive care, considering the patient’s needs, an appropriate attitude of the staff, and providing accurate and clear information to patients certainly encourage appropriate behaviour of healthcare clients and prevent their aggressive behaviour.

In the future, consideration should be given to ensuring adequate protection for medical staff and organizing training in patient management.

This study had several limitations. The research could have been carried out in a larger study group, including more nurses and other medical facilities. It would allow for a more accurate understanding of the causes and manifestations of aggression among hospitalized patients.

Conclusions

In professional work, nurses encounter aggression from patients. The lower the suppression of emotions, the more adequate the perception of aggressive situations. Shorter waiting times for medical services or examinations may contribute to a lower number of aggressive behaviours of patients.

Conflict of interest: None.

Funding: None.

References