New nurses face endemic violence: New Zealand research on the incidence of violence faced by new graduate nurses reveals some disturbing findings. All nurses have an obligation to respond to this insidious behaviour.

THE NATIONAL Business Review conducts an annual poll each year called the Respect List. A random sample of the public is asked to rate a number of professions according to the amount of respect they have for the work of each profession. Nurses have scored the highest respect ratings every year since the poll began in 1992. (1)

Yet surveys of nurses indicate that this respect is not always mirrored in the public's behaviour towards nurses. Nursing research indicates a disturbingly high prevalence of violence in health care settings, with nurses the most at-risk health professionals. (2,3,4)

The research also highlights physical and psychological consequences for nurses as victims of patient violence; the negative effects the experience has on professional development and retention rates; (5,6,7) the in adequacy of nurse education in addressing these concerns; and the low reporting of patient violence to workplace authorities. (8)

The first year of practice is traditionally highlighted as an important "confidence building" phase for new graduate nurses. Yet there is a no research, to our knowledge, which focuses on new graduates' experience of patient violence.

We took our initial interest in doing such research to a group of new graduate nurses. Although they thought the idea was worth pursuing, they believed there was a more pressing concern regarding violence. This related to the inappropriate behaviour experienced by some new graduate nurses from their colleagues. This intra-collegial violence is labelled "horizontal violence" or "bullying". The literature abounds with anecdotal accounts of its existence. Horizontal violence does not usually involve physical force but takes the form of psychological harassment, involving both overt verbal abuse, threats, intimidation, humiliation and excessive criticism; and covert innuendo, exclusion, denial of access to opportunity, disinterest, discouragement and the withholding of information. (9,10)

To consider the issues of both patient violence and horizontal violence, we did two studies within a national survey of new graduate registered nurses (RNs) in 2001. The goals of the first study were to determine the prevalence of various types of threats and assaults by patients against nurses in their first year of practice; to describe the characteristics of the most distressing incidents these nurses experienced; to measure the psychological impact of these events; to determine the adequacy of training received to manage aggression; and to elicit response strategies to enable nurses to cope with such events. The second study had the same aims as the first but considered horizontal violence, rather than patient-nurse violence.

The majority of the research team were academics and therefore there was an academic agenda associated with completion of the research. This agenda was to further international understanding of the issues, by having the research reported in high-impact, peer-reviewed journals. The intent was to stimulate further research, all of which should create a knowledge base, which feeds back into practice. In both regards we have had success. Both studies have been published in peer-reviewed journals of repute. (11,12) Following publication, there has been correspondence from as far afield as the United States, Scotland and China, requesting our survey questionnaire as a basis for further research.

However, having achieved these goals does not exclude us from the obligations to make sure our participants are well in formed about the outcomes of the research and to be involved in practical steps toward resolution of the issues arising from the research. The intent of this article is to reflect on what can be done. In order to do this, we need to give a brief overview of the research and the research findings.

Research overview

Method: In 2001 we conducted a national survey of nurses in their first year of practice. In the survey we considered a broad view of violence from verbal abuse to physical assault. We included unwanted physical and sexual contact, and racist comments and gestures. With horizontal violence, we considered the same overt behaviour as well as the prevalence of the covert behaviours previously mentioned.

Respondents were also asked to describe in detail the one incident that had caused them the most distress. This incident could be inappropriate behaviour by a patient or by a nursing colleague. A validated and reliable measure of current subjective psychological distress, the Impact of Event Scale, (13,14) was used to measure the level of distress experienced from that event over the preceding seven days prior to completing the questionnaire. Nurses were also asked about education concerning violence, and any debriefing following the incident.

The sample group was accessed through the Nursing Council. The Council was contracted to mail out an information letter and an anonymous questionnaire to RNs in their first year of practice. This involved all nurses residing in New Zealand, who had registered in the year prior to November 2000. Two reminder letters were sent out over three months. Funding for the research was through the Auckland University of Technology and the Nursing Education and Research Foundation of NZNO.

From the 1169 mail-outs, we received 551 completed surveys, a 47 percent response rate. This was a favourable response, given the low response rate of 30 percent associated with anonymous mail-out surveys. (15) We gathered data on demographic and workplace variables, which mirrored that collected by the Nursing Council when eligible participants registered. Therefore the representativeness of the sample was able to be determined.

Major findings

Patient violence: The most common inappropriate behaviour by patients involved verbal threats, verbal sexual harassment and physical intimidation. However, there were 22 incidents of assault requiring medical intervention and 21 incidents of participants being stalked by patients. Other significant findings were:

* New graduates in mental health services were more likely than new graduates in all other services combined to report having experienced most of the categories of behaviour.

* The most distressing incidents described by participants included an act of arson in a ward, an attempt to strangle a nurse, a threat of inflicting Aids with a syringe, a threat of rape, and stalking outside the hospital environment.

* Two participants scored at a level indicative of the symptoms of post traumatic stress disorder on the Impact of Events Scale.

* Sixteen respondents indicated that they had considered leaving nursing as a consequence of the incident.

* There was evidence of under-reporting of incidents.

* Debriefing following the incidents did not often occur.

* Undergraduate education and post-registration training were described as providing inadequate preparation for coping with such behaviour.

Horizontal violence: Overt violence, except verbal humiliation, was uncommon. Other significant findings were:

* Covert expressions of horizontal violence were endemic, eg more than half the participants reported being undervalued by other nurses.

* The most distressing incidents described by participants tended to be prolonged and protracted, involving such behaviour as sexual harassment with the promise of employment for compliance with sex, and colleagues "setting up" a nurse to be exposed to sexually inappropriate behaviour from patients.

* Twelve participants scored at a level indicative of the symptoms of post traumatic stress disorder on the Impact of Event Scale.

* Fifty-eight respondents indicated they had considered leaving nursing as a consequence of the incident.

* There was evidence of under-reporting of incidents.

* Debriefing following the incidents did not often occur.

* Undergraduate education and post-registration training were described as providing inadequate preparation for coping with such behaviour.

Discussion

For new graduate nurses, horizontal violence is endemic, while those working in mental health service areas are the most at risk from patient violence. The results indicate the need for comprehensive solutions to address the needs of new graduate nurses.

Some solutions belong to the profession, such as zero tolerance to violence campaigns in clinical settings, similar to those that have been conducted overseas. Others are service provider responsibilities, including "safe" reporting processes; security personnel and technology; and debriefing processes that alleviate psychological distress. There is also an obligation on services to develop appropriate protocols to prevent and address violence.

In some circumstances it may be appropriate to alert police to determine the need for charges to be laid over violent behaviour. It is, therefore, important that protocols have a "careful, consistent, comprehensive and ethically principled approach". (16) The Ministry of Health is presently drafting a document to assist services in this regard. (16)

Role of education: As educators, we wish to comment on the role of education in working with violence. Primary prevention begins with education and training. Violence in all forms needs to be addressed in the curriculum of undergraduate nursing programmes and in the development of programmes supporting new graduates in their first year of practice.

Education needs to include theory on aggression, risk assessment, reporting mechanisms, de-escalation through communication skills, breakaway skills to maintain personal safety, coping mechanisms and, within specialty areas such as mental health, the development of calming and restraint techniques to safely contain violence.

In New Zealand, first-year-of-practice programmes exist in some district health boards. The model espoused indicates that each programme must have a curriculum, which integrates theory and practice. The role of a preceptor is seen as a panacea in this integration. (17) The programme frame work allows for a reduced workload for both preceptors and new graduates, so a supportive learning environment may be developed. The programmes can be delivered by a health service provider, with or without the collaboration of an education provider. (18)

Although the curricula of these programmes should rightly be practice centred, we recommend they should also emphasise "transformatory learning". The concept of transformatory learning is derived from critical social theory. It involves critical reflection on the context within which practice occurs, and encourages a proactive response to the critique. (19,20)

We acknowledge that this process may be hard for some preceptors to engage in, given their position within the institutional hierarchy. As shown in our research, some preceptors may be involved in horizontal violence, thus there is a priority for preceptors to receive ongoing training, managerial accountability, support, and feedback on their effectiveness.

Furthermore, there is the need for external supervision to engage graduate nurses in the process of reflection on practice. (21) This external supervision could be under taken by trained independent practitioners or external educators.

Given both the complexity of curriculum development and the need for external supervision, it is imperative that collaboration between health service providers and education providers is mandatory rather than discretionary, within the development of these programmes. Furthermore, little is known about the effectiveness of the suggested strategies in reducing incidents of violence. Evaluation research should be an integral part of education programmes already in place.

Finally, we realise we have highlighted a "problem", though we do so with a commitment to work toward a resolution. We have presented our findings in a variety of forums nationally and to DHB nurses and managers.

However, the numbers attending such forums are limited, whereas the circulation of Kai Tiaki Nursing New Zealand is considerable [32,000, Ed.]. We hope this mass dissemination of the findings will prompt action. The findings of this research place an obligation on us all to address the is sues in whatever context we are influential--be that within professional organisations, service leadership, education or clinical practice.

The obligation requires us to have the right systems supporting our practice. However, ultimately the obligation comes down to how we treat and support each other.

REFERENCES

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(12) McKenna, B., Poole, S., Smith, N., Coverdale, J., & Gale, C. K. (2003) A survey of threats and violent behaviour by patients against registered nurses in their first year of practice. International Journal of Mental Health Nursing 12: 1, 56-63.

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(15) Gillham, B. (2000) Developing a questionnaire. London: Continuum.

(16) Ministry of Health. (2004) Draft National Protocol for Responding to Allegations of Criminal Conduct within Mental Health Services. Wellington: Ministry of Health.

(17) Ministry of Health. (2001) Draft specification for new graduate first year of nursing clinical practice--District Health Board pilot programmes. Wellington: Ministry of Health.

(18) Nursing Council of New Zealand. (2001) Framework for Post-Registration Nursing Practice Education. Wellington: Nursing Council of New Zealand.

(19) Freshwater, D. (2000) Crosscurrents: against cultural narration in nursing. Journal of Advanced Nursing; 32: 2, 481-484.

(20) Roberts, S. (2000) Development of a positive professional identity: Liberating oneself from oppression. Advances in Nursing Science; 22: 4, 71-84.

(21) Jones, A. (1997) Clinical supervision in moderating organisational conflict and preserving effective working relationships. International Journal of Palliative Nursing; 3: 5, 293-299.

Brian McKenna, RCpN, BA, MHSc (Hons); senior lecturer, School of Nursing, the University of Auckland; nurse adviser, Auckland Regional Forensic Psychiatry Services, Waitemata District Health Board, Auckland.

Suzette Poole, RPN, Cert. in Psychiatric Forensic Care; director of mental health nursing, Waikato District Health Board. Naumai Smith, RGON, BA, MHSc; senior lecturer, School of Nursing and Midwifery, Auckland University of Technology.

John Coverdale, MBChB, FRANZCP; associate professor, Division of Psychiatry, the University of Auckland.