Editorial: Five years of scholarship on violence, bullying and aggression towards nurses in the workplace: what have we learned?

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Workplace violence in its various forms is a continuing concern for nurses. Few nurses are completely untouched by this violence, with many being exposed to violence and aggression in their day-to-day work. The discourses on violence in nursing and health care tend to capture a range of phenomenon including overt and covert acts of violence, bullying and aggression (VBA) originating from patients/clients and their families or companions, and colleagues, other workers and managers. Reflecting the ongoing concern about VBA, it is important that we continue to strive to understand its impact on nurses and those in their care and find ways to move forward to both address the harm caused and find solutions. We have drawn together a group of papers that have appeared in Journal of Clinical Nursing over the past 5 years (see Table 1) to give an overview of the range of contemporary international work in the area.

Table 1. Focus, approach, sample and country of papers
Focus of paperApproachSampleCountry
Interventions to reduce violent acts towards ED nursesReviewLiterature reviewInternational
Violence in the EDReviewLiterature reviewInternational
Prevalence and characteristics of workplace violence to nursesSurveyNursesAustralia
Safety and security measures in acute psychiatrySurveyHealth personnelUnited Kingdom
Patient and visitor violenceSurveyNursesSwitzerland
Nurse perceptions of the reality of practiceQualitativeNursesNew Zealand
Nature of workplace bullyingQualitativeNursesAustralia
Female perceptions of workplace violenceQualitativeHealth personnelSweden
Violence associated with community care of older peopleSurveyNursesSweden
Under-reporting of violenceSurveyNursesUnited Kingdom
Meanings of violence from nurses' perspectiveQualitativeNursesAustralia
Risk factors and sequelae of violence to nursesSurveyNursesTaiwan
Verbal and physical violence experienced by nursesSurveyNursesTurkey
Antecedents of bullying and violenceSurveyNurses and midwivesAustralia
Mobbing in the workplaceSurveyNursesTurkey
Perceived aggression towards nursesSurveyNursesItaly
Nurses perceptions of psychological violence in the workplaceInstrument developmentNursesTurkey
Patient and visitor violenceInstrument testing and modificationNursesSwitzerland

So what can we take from these papers? When read as a single discourse, these papers reinforce the idea that many nurses work within environments that feature VBA and situations of disagreement and conflict. The evidence suggests that this exposure can be multidimensional and high density, creating a complex interplay that not only impacts individuals but also has the potential to shape workplace relationships and practices (Yildirim & Yildirim 2007). Studies emerging from countries where little work has yet been undertaken to examine or understand VBA experienced by nurses remind us of the gendered and often sexualised nature of these experiences (Pai & Lee 2011, Zampieron et al. 2011).

These papers also highlight how per-sistent and repeated exposure to vio-lence and hostility can insidiously erode emotional well-being, motivation, work performance and job satisfaction (Rodwell & Demir 2012) as well as work group norms and social identity (Yildirim & Yildirim 2007). There is evidence that in some contexts, strategies to address violence from care recipients have resulted in increased confidence among nurses in responding to and reducing violence (Lovell et al. 2011). However, in other contexts, even though reporting processes and policies have been in place for some time, violence remains under-reported (Luck et al. 2008, Chapman et al. 2010) or policy remains underdeveloped in addressing the specific issues nurses face in certain clinical settings (Cowman & Bowers 2008).

Survey approaches dominate this collection of papers, with fewer qualitative and review papers. Studies using surveys often employed a list of behaviours with self-report of exposure used as a sole measure of determining frequency of exposure (Josefsson et al. 2008, Lovell et al. 2011). These studies evidence the extent of the problem as reported by nurses and lead to calls for interventions largely in terms of policy or education. While understanding the extent of the problem is important, research thus far has focused upon small, institution or country-specific prevalence studies for what is in fact a global issue. The need for appropriate measures is in evidence through two papers focussing on instrument development and refinement (Dilek & Aytolon 2008, Hahn et al. 2011). The opportunity for large multinational studies cannot be ignored, and the importance of valid culturally appropriate instruments is the first step in moving forward in this area.

Violence, bullying and aggression seems to take place within an environment of acquiescence, in that aggressive and hostile behaviours are frequently enacted in front of others, and so there is a need to understand the cycle of enculturation and bystander non-intervention in either tolerating or passively witnessing unacceptable behaviour. The rites and rituals perpetuated in hostile work environments can challenge the personal moral identity of individuals, particularly when the tolerance of behaviours such as bullying is how individuals gain access to, or the support of, the group. Importantly, there is an absence of exploration on the ethical implications of hostile work environments and behaviours, and the effects that working in an environment of VBA has on workplace culture, leadership and ethical workplace behaviour, particularly over time. Failing to examine these issues is problematic in that there may be the potential to mitigate inappropriate workplace behaviour through peer messages of unacceptability, and indeed, such strategies may already be in place in some settings. However, the limited understanding of these behaviours within nursing workgroups limits the type of intervention strategies employed.

The literature is strongly informed and shaped by data arising from health professionals, mainly nurses. Yet, there is also a need to explore how VBA erodes, changes or hampers nursing practice and patient care – these are important considerations, particularly for us because of the clinical focus of the Journal of Clinical Nursing. However, although these issues may not be specifically addressed as yet, the current discourse suggests it is likely that bullying is commonly enacted in front of patients, or in ways that directly implicate patients or patient care (Hutchinson et al. 2010). Furthermore, while the predominant focus upon nurses has generated enhanced understandings of the perspectives of nurses in relation to VBA, it has largely failed to capture the perspectives of care recipients and their families with little known about the experiences (or its impact) of witnessing VBA among healthcare staff, upon patients, their family or caregivers. While it may be reasonable to assume that confidence in care could be eroded, or the capacity of patients and family to raise care concerns silenced, research into this area could provide crucial evidence into the views and experiences of patients and family members, enhance disciplinary knowledge and act as a catalyst for real change in the area. In addition, little is known about the prevalence and nature of VBA that might be either directed at or experienced by patients themselves.

In reviewing this group of papers, it is evident that we have learnt much over the time these papers were written. In continuing to develop the professional discourse in the area, and distilling areas for further research, we encourage a continued extension of work in this field. Extending scholarship into new areas will help ensure we do not become desensitised to what is an unacceptable yet common feature of nursing work, and could create the knowledge that could ultimately reduce VBA in the health care environment.

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