Aggression in Healthcare

Aggression was, in 1968, described by Moyer as “a behaviour that causes (or leads to) harm, damage or destruction of another organism” (Weinshenker and Siegel 2002). Human aggression has more recently been defined as “any behaviour directed toward another individual that is carried out with the proximate intent to cause harm” (Anderson and Bushman 2002).

The definition can be extended to include the fact that aggression can be physical, verbal, active or passive and be directly or indirectly focussed at the victim–with or without the use of a weapon, and possibly incorporating psychological or emotional tactics (Rippon 2000). It requires the perpetrator to have intent, and the victim to attempt evasion of the actions. Hence harm that is accidental cannot be considered aggressive as it does not incorporate intent, nor can harm implicated with intent to help (for example the pain experienced by a patient during dental treatment) be classed as aggression as there is no motivation to evade the action (Anderson and Bushman 2002). A description of workplace violence by Wynne, Clarkin, Cox, & Griffiths (1997), explains it to involve incidents resulting in abuse, assault or threats directed towards staff with regard to work–including an explicit or implicit challenge to their safety, well-being or health (Oostrom and Mierlo 2008).

Aggression in the Healthcare Industry
Professions within the healthcare industry are becoming increasingly violent places in which to work–with healthcare professionals being common targets for violent and aggressive behaviour (Rippon 2000).

Aggression and violence negatively impact both the workplace and its employees. For the organisation, greater financial costs can be incurred due increased absences, early retirement and reduced quality of care (Arnetz and Arnetz 2000; Hoel, Sparks, Cooper, 2001). For the healthcare worker however, psychological damage such as post-traumatic stress can result (Rippon 2000), in addition to a decrease in job motivation (Arnetz and Arnetz 2000).

Classifying Aggression

 * Classification (LeBlanc and Barling 2004):
 * Patient-on-Professional aggression can be classified as Type II; where the perpetrator commits a violent act whilst being served by the organisation, with which they have a legitimate relationship (LeBlanc and Barling 2004). It is uncommon for such attacks to result in death (Peek-Asa, Runyan, Zwerling 2001), however they are evidently responsible for approximately 60% of non-fatal assaults at work (Peek-Asa and Howard 1999).


 * Within this classification that is based on the relationship between the perpetrator and victim, Type I aggression involves the perpetrator entering the workplace to commit a crime–having no relationship to the organisation or its employees. Type III deals with a current/former employee targeting a co-worker or supervisor for what they perceive to be wrong-doing. Type IV aggression involves the perpetrator having an ongoing/previous relationship with an employee within the organisation. (LeBlanc and Barling 2004).

Conceptual Model 1 (Nijman et al. 1999)

 * Internal Model:
 * The internal model associates aggression with factors within the person, including mental illness or personality (Duxbury et al. 2008). This model is supported by the numerous studies correlating a link between aggression and illness (Duxbury and Whittington 2005). A person’s traits can relate to their expression of aggression–narcissists for example, tend to become angry and aggressive if their image is threatened (Anderson and Bushman 2002). Sex tends to affect aggression–with certain provocations affecting each sex differently (Bettencourt and Miller 1996). It was found that males tend to prefer direct aggression, and females indirect (Österman et al. 1998) (Anderson and Bushman 2002). A study by Hobbs and Keane, 1996 explains that patient factors commonly related to or causative of patient violence include; male sex, relative youth or the effects of alcohol or drug consumption (Hobbs and Keane 1996). A study conducted amongst General Medical Practitioners in the West Midlands found that men were involved in 66% of aggression cases; rising to 76% with regard to assault/injury (Hobbs and Keane 1996)–the main male perpetrator being aged under 40 years of age. Patient anxiety, a particular problem associated with dentistry, tended to be the most likely instigator for verbal abuse and the second most likely reason for threatening verbal abuse (Hobbs and Keane 1996).


 * External Model:
 * This model is based on the idea that social & physical environmental influences affect aggression (Duxbury et al. 2008). This includes the provisions for privacy, space and location (Duxbury and Whittington 2005). Motivation for aversion, possibly due to pain during dental treatment, can increase aggression (Berkowitz, Cochran, Embree 1981)–as can general discomfort, such as that resulting from sitting in a hot waiting room (Anderson, Anderson, Dorr 2000) or in an uncomfortable position (for example in a reclined dental chair) (Duxbury et al. 2008). Alcohol intoxication or excessive caffeine intake tends to indirectly exacerbate aggression (Bushman 1993). The Hobbs & Keane (1996) study states the involvement of drugs and alcohol; in 65% of cases at one Accident & Emergency Department and in 27% of all general practice cases. The study denotes intoxication to be the main reason for assaults and injury (along with mental illness) (Hobbs and Keane 1996). Frustration, defined by Anderson and Bushman (2002) as “the blockage of goal attainment”, can also contribute to aggression–whether the frustrations are fully justified or not (Dill and Anderson 1995). Such frustration-related aggression tended to be against the perpetrator and persons not involved in failure to reach the goal. Prolonged waiting times in A&E departments and general practice led to aggression due to frustration; it generally being directed towards receptionists–with approximately 73% of doctors becoming involved (Hobbs and Keane 1996).


 * Situational/Interactional Model:
 * This deals with factors involved in the immediate situation, for example interactions between patients and staff (Duxbury et al. 2008). There a numerous studies that support the correlation between staff with a negative attitude and patient aggression (Duxbury and Whittington 2005). Provocation has been said to be the most important cause of human aggression (Anderson and Bushman 2002)–examples include verbal and physical aggression against the individual (Anderson and Bushman 2002). It was found that perceived injustice, in the context of equality amongst staff for example, positively correlated to workplace aggression (Baron 1999).

Conceptual Model 2 (Baron 1999)

 * Expressions of Hostility:
 * This is related to “behaviours that are primarily verbal or symbolic in nature” (Baron 1999). In terms of Staff-on-Staff hostility, this can involve he perpetrator talking behind the targets back. With Patient-on-Professional hostility however, this can deal with the patient assuming false knowledge over the professional–with the patient belittling their opinions (Baron 1999).


 * Obstructionism:
 * This involves the perpetrator conducting actions that aim to “obstruct or impede the target’s performance” (Baron 1999). Failures to pass on information or respond to phone calls for example, are ways in which Staff-on-Staff obstructionism can be demonstrated. Patient-on-Professional obstructionism can be demonstrated by a failure on behalf of the patient to comply with the professional conducting a certain task. An unwillingness to allow the professional to diagnose the patient and a failure to turn up to appointments are examples of such obstructionism.


 * Overt Aggression:
 * This normally relates to workplace violence, and involves behaviours including; threatening abuse, physical assault and vandalism (Baron 1999). This again can occur with regard to both, Staff-on-Staff and Patient-on-Professional aggression.

Buss’ Three-Dimensional Model of Aggression (1961)
Buss (1961) differentiated aggression into a three dimensional model; physical-verbal, active-passive and direct-indirect–active-passive being removed in 1995 when Buss refined the categories. Physical assault would come under the category physical-direct-active, whereas obstructionism relates to physical-passive–be it direct or indirect. Verbal abuse or insults relate to verbal-active-direct aggression, whereas the failure to answer a question when asked, for example with regard to lifestyle choices or habits, can come under the verbal-passive-direct category–providing the reasons for not answering are directed at the healthcare worker (e.g. hostility), as opposed to fear for example (Rippon 2000).

The Prevelance of Aggression within the Healthcare Industry
A survey from the British National Audit Office (2003) stated that violence and aggression accounted for 40% of reported health & safety incidents amongst healthcare workers (Oostrom and Mierlo 2008). Another survey looking into the violence and abuse experienced in 3078 general dental practices over a period of three years found that 80% of practice personnel had experienced violence or abuse within the workplace, which included verbal abuse and physical assault (Pemberton, Atherton, Thornhill, 2000). It was reported that, over 12 months in Australian hospitals, 95% of staff had experienced verbal aggression (O'Connell et al. 2000). Moreover, in the UK over 50% of nurses had experienced violence or aggression over a 12 month period (Badger and Mullan 2004).

Coping with Aggression in Healthcare
When dealing with aggression and violence in the workplace, training and education are the primary strategy for resolution (Beech and Leather 2006). There are a number or personal factors that can help reduce aggression within the healthcare setting, which include improved interpersonal skills, with an awareness of patient aggression and knowledge regarding dealing with emotional patients (Oostrom and Mierlo 2008). Although assertiveness is crucial when it comes to the interpersonal skills possessed by healthcare workers, it has been shown by numerous studies that nurses tend not to be very assertive (Oostrom and Mierlo 2008). Training is therefore usually offered by organizations with regard to assertiveness, and deals mainly with improving self-esteem, self-confidence and interpersonal communication (Lin et al. 2004).

The Health Services Advisory Committee (HSAC) recommends a three-dimensional foundation by which to deal with violence in the workplace. It involves “researching the problem and assessing the risk, reducing the risk and checking what has been done” (Beech and Leather 2006).

In 1997, HSAC provided the following guidelines as to what good training involves (Beech and Leather 2006):
 * Theory: To understand the aggression within the workplace
 * Prevention: To assess the danger and take precautions
 * Interaction: With aggressive individuals
 * Post-Incident Action: To report, investigate, counsel, and follow up the incident

Assertive Training (Lin et al. 2004)
Although many studies looking at the effectiveness of training have provided inconclusive results (Oostrom and Mierlo 2008), a study by Lin et al. (2004) positively correlated the improvement of assertiveness and self-esteem with an assertiveness training programme (Lin et al. 2004). The programme targets difficult interactions that we may face in day-to-day life and includes both, behavioural and cognitive techniques (Lin et al. 2004). The effectiveness of training is measured using the Assertive Scale, Esteem Scale, and Interpersonal Communication Satisfaction Inventory (Lin et al. 2004).

Evaluating the Effectiveness of Training
It remains that training is not universally or consistently offered to healthcare workers (Beech and Leather 2006). Beale et al. (1998) found that the levels of training offered ranged from nothing to high-level restraint/self-defense training. A report by the National Audit Office (NAO) in 2003 found that, within mental health trusts, a reactionary approach tends to prioritise over prevention. Although criticised by many; restraint, seclusion and medication are used (Wright 1999, Gudjonsson et al. 2004) (Duxbury and Whittington 2005). Breakaway techniques, restraint, rapid tranquilisation or isolation tend to be recommended when violence is instigated with a failure to prevent aggression (Duxbury and Whittington 2005). This correlates to the level of training offered, which dominates in these areas, however lacks in situation risk assessment and customer care (Beech and Leather 2006)–methods that are vital in a preventative approach to prevent escalation of the situation, causing for reactionary measures to be brought into play.

The study by Beale et al. (1998) therefore provides the following advice as to good practice (Beech and Leather 2006):
 * Training should emphasise prevention, calming and negotiation skills as opposed to confrontation
 * Training should be offered in modules, ranging initially from basic customer care and handling difficult patients to full control and restraint of patients.
 * Material relating to the causes of aggression, how to reduce risks, anticipation of violence, resolving conflict and dealing with post-incident circumstances should be provided to staff.
 * Physical breakaway skills should be taught–however an understanding as to situations in which such skills should be practiced must be appreciated.
 * Staff should be taught to control their own feelings
 * An understanding of normal/abnormal post-trauma reactions should be reached
 * Staff should be familiar with local arrangements and policies