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NURSING AFTER SUNSET Violence & Aggression from a Night Shift Perspective

NURSING AFTER SUNSET Violence & Aggression from a Night Shift Perspective. Mr. Joseph Galea RMN, RGN. B.Sc.(Hons.) Mental Health Nursing, BBA(Hons.) Business Administration, Cert. Subst. Misuse (UK) Departmental Nursing Manager - MCH MAPN Conference 2nd November 2012.

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NURSING AFTER SUNSET Violence & Aggression from a Night Shift Perspective

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  1. NURSING AFTER SUNSETViolence & Aggression from a Night Shift Perspective Mr. Joseph Galea RMN, RGN. B.Sc.(Hons.) Mental Health Nursing, BBA(Hons.) Business Administration, Cert. Subst. Misuse (UK) Departmental Nursing Manager - MCH MAPN Conference 2nd November 2012

  2. 1. Antecedents to Violence & Aggression 2. Night-Shift & Violence 3. Effects of Violence & Agression 4. Deescalation of a Crisis 5. Night-Shift 6. Effect of Night-Shift 7. Sleep Disorders & Fatigue 8. Under-reporting of Violence & Aggression Incidents 9. Recommendations Aims of the Presentation

  3. Introduction (i) • Prevelance of violence in healthcare (Duncan et al., 2001; Gerberich et al., 2004; Lanza, Zeiss & Reirdan, 2006a) • Particularly on nursing staff (Findroff et al., 2004; Hodgson et al., 2004; Lanza, Zeiss & Reirdan, 2006b) • Impact on the physical & psychological health (Gerberich et al., 2004; Lanza, 1983, 1992; Lanza et al., 2006a; Woods & Ashley, 2007) • Impact on the ward environment and patients’ care (Flannery et al., 1995; Morrison, 1990)

  4. Antecedents to Violence & Aggression (i) • Perpetrators of physical violence = patients (Acik et al., 2008; Chen et al., 2008) • Lateral violence = perpetrators of psychological violence = staff members, co-workers & supervisors (King & McInerney, 2006; Kwok et al., 2006; Johnson et al., 2007; Bigony et al., 2009) • Reasons for aggressive & violent behaviour – patients and nurses disagree – patients: environmental conditions + poor communication; nurses: patients’ mental illness (Duxbury & Whittington (2005) • Complex interactions of patients, staff and culture of a specific unit (Hamrin et al., 2009)

  5. ANTECEDENTS to Violence and Aggression Medication Related Containment 2) Staff-Patient Interaction 1) Patient – Patient Interaction 8) Patient Symptoms Any other containment Any other staff-patient interaction Violence & Aggression 3) Patient Conflict Behaviors 5) Structural Issues Environmental Issues Regime Issues 7) Patient Emotional Cues 6) Patient Behavioral Cues 4) External / Personal Issues

  6. Physical contact Intrusion into personal psychological or physical space (BAAEM, 2003; McPhauls & Lipscomb, 2008; May & Grubbs, 2002; Presley & Robinson, 2002) Competition Patient engaged in an activity Reaction to sexual approach Miscummunication Victim doing something patient wanted stopped Retaliation Patient victim characteristics Teased / bugged Provocation (Powell et al., 1994) Difference in language and culture (Mallet & Dougherty, 2000) Patient to Patient Interaction (Bowers et al. 2011)

  7. Limiting patients’ freedom: (Sheridan et al., 1994; Lancee et al., 1995; Davis, 1991) and the limit style of nursing staff(Lancee et al., 1995; RCP, 2000) Medication related containment: a) medication administration, b) staff requesting patient to take medication, c) dispute over medication (Sheridan et al., 1990; Powell et al., 1994; Lancee et al., 1995; Davis, 1991) Any other containment: a) restraint, b) seclusion, c) de-escalation, d) ECT, e) involuntary admissions (Fineberg et al., 1990; Powell et al., 1994) Any othe staff-patient interaction: a) provocation. b) ordering patients, c) intervening on fight or argument, d) caring for patient, e) searching patients, f) negative staff attitude (OSHA, 2003; BAAEM, 2003), g) physical contact, h) patient engaged in an activity, i) miscommunication, j) staff too permissive, k) staff victim characteristics, l) staff errors, m) violation of priority (Mallet & Dougerty, 2000), n) lack of information(Mallet & Dougherty, 2000), o) access to staff(McGeorge et al., 2000). Staff-Patient Interaction (Bowers et al. 2011)

  8. Patient conflict Behaviors(Bowers et al. 2011) : a) threatening behaviour, b) abscondments, c) substance misuse (BAAEM, 2003; Johnson, 1997), d) verbal agression, d) self-harm. External / Personal(Bowers et al. 2011) : a) money issues, b) visit from family member or friend(Henry & Ginn, 2002) (BAAEM, 2003), c) receiving bad news, d) unresolved family problem. Structural & Environmental issues(Bowers et al. 2011) : a) overcrowding (Fineberg et al., 1990; Palmstierna et al., 1991; Lanza et al., 1994), b) confined environment, c) noisy ward, d) patients found weapons, e) social environment such as boredom (RCP, 1998; RCP, 2000). Regime issues (Bowers et al. 2011): a) inadequate staffing levels (McPhaul & Lipscomb,2008; Gilmore-Hall, 2001, b) admitting / transferring / discharged & when pts ask to discharge themselves against medical advice (Sheridan et al., 1990;Powell et al., 1994; Lancee et al., 1995; Davis, 1991), c) excessive sensory stimulation, d) lack of stimulation. Patient Behavioral cues (Bowers et al. 2011): a) agitation, b) attention seeking behavior, c) increased motor activity, d) confusion. Patient emotional / mood cues (Bowers et al. 2011) : a) anger, b) sexual frustration, c) irritability, d) tobacco withdrawal, e) Delusions(Humphreys et al., 1992)& hallucinations (Dura, 1997),and stress due pain or illness (ICN, 2002; McPhauls & Lipscomb, 2008).

  9. Night-Shift & Violence (i) • Violence experienced during night-shifts (Arnetz et al., 1996) particularly before 11pm. • Mostly occured during the afternoon – 3pm to 11pm (Bradley et al., 2001) – lack of structured interaction (Drinkwater, 1982; Rice et al., 1989) • There is no consensus. • Specific times for aggression: during admission – change of shifts – mealtimes (Pearson et al., 1986) – visiting hours (Way et al., 1992) – administration of medication (Walker & Siefert, 1994; Barnard et al., 1984; Depp, 1983).

  10. Figure 1: Peak times for violent incidents FREQUENCY TIME Bowers et al., 2011

  11. Night-Shift & Violence (ii) • Highest numbers of incident occurred between 7am – 3.30pm (morning shifts, 49% of the incidents); high number on afternoon shift (36%); during night (15%) (Barlow et al., 2000) • Aggression a daytime phenomenon (Barlow et al., 2000; Way et al., 1992; Shah et al., 1991) • Patients on leave – evening on return to the ward (Nobel & Rodger, 1989) • Preventing a patient leaving the ward (Walker & Siefert, 1994) • Staff uncertain of their roles (Katz & Kirkland, 1990) • Substitute nursing staff (James et al., 1990) • Higher staff to patient ratio(Morrison, 1990; Kalgerakis 1973; Depp, 1983) – more than 1:1 (Lanza et al., 1994)

  12. FIG 1: Peak shifts for violent incidents FIG 2: Location of violent incidents FREQUENCY % SHIFT LOCATION Bowers et al., 2011

  13. Staff – nurses (90% of incidents)(Edwards et al., 1988; Noble & Rodger, 1989) Patients (30%) were against patients(Noble & Rodger, 1989) Provoked by patients, relatives or visitors(Powell et al., 1994). Physical injuries(Chen et al., 2008) Psychological trauma(Chen et al., 2008) & PTSD (Caldwell, 1992; Mikkelsen & Einarsen, 2002; Hansen et al., 2006; Bigony et al., 2009) Negative impact on the mental health of nurses(Pai & Lee, 2011) Emotional reactions following violence include antipathy against perpetrator, insult and fear(Astrom et al., 2004) Negative organisational outcomes(Estryn-Behar et al., 2008; DHHS/NIOSH, 2002) Victims of in-patient violence Effects of Violence & Aggression

  14. De-escalation of a Crisis • ‘Calming the patient’ – shift from a dominant-submissive connotation to collaboration (Richmond et al., 2012). • De-escalating a patient = form of a treatment = develop internal locus of control (Richmond et al., 2012). • This involves rapid assessment & decision-making skills

  15. Good attitude Observation skills – verbal & non-verbal skills Risk Assessment skills Communication skills Listening skills (active listening) Active listening skills Emotional intelligence – self-monitoring Positive regard Empathic Quick decision making skills Assertiveness skills Team coordination skills Coaching skills Limit settings Motor skills Offer choices and optimism Restraining skills Debriefing skills Skills Needed (Richmond et al., 2012)

  16. Night-Shift (i) • Work performed after 6pm and before 6am the next day. (Abdalkaber & Hayajneh, 2008) • Activity at night = out of phase with the circadian body temperature. = desynchronised state. (Abdalkaber & Hayajneh, 2008) • This disorientation = health & psychological effect of fatigue. (Abdalkaber & Hayajneh, 2008)

  17. What these three sets of pictures have in common?(Rogers et al., 1997; Harrington, 2001)

  18. Night-Shift (ii) • To ensure patient’s coverage nurses have to work nights, weekends and holidays. • Night nurses have higher levels of fatigue (Muecke, 2005) and mental tiredness (Tepas et al., 2004), chronic sleep loss, sleep deprivation and on-the-job sleepiness (Hughes & Stone, 2004). • Rarely get the recommended 8 hrs of sleep (Akerstedt, 2003). • Suffer from sleep disturbances (Barton, 1994) – which may have an impact on patients’ safety. • Less quality sleep then those working during the day (Ruggiero, 2003; Frank & Ovens, 2002). • Sleep deprivaton – work performance outcomes – safety and general health of the nurse (Rogers et al., 2004)

  19. Night-Shift (iii) • The 2nd half of the night is where nurses reported that they frequently struggle to stay awake (Berger & Hobbs, 2006). • Staff’s circadian rhythm – social – family life – general health affected (Rosa & Collingan, 1997). • Nurse who work nights are more depressed than day nurses (Ruggiero, 2003) / there is an association between night work and poor job satisfaction (Korompeli et al., 2009). • Staff performance: Significant associations between night staff and error rate (Gold et al., 1992; Leff et al., 2008).

  20. Effects of Night-Shifts • Two things wrong with shift-work: • Having to work when supposed to sleep • Having to sleep when supposed to be awake • For some people, this can result in performance, health and social effects • Fatigue = less work performance + short staffing = less the quality of patient care (Circadian Technologies, 2004) • Breast Cancer to be 60% higher in women night-shift workers (Humm, 2005; Swerdlow, 2003; Steven & Davis, 1996) infertility, cardiovascular disease, diabetes and gastrointestinal disorders (Humm, 2005; Reid et al., 1997; Learhart, 2000). • Fatigue, irritability (Lushington et al., 1997; Reid et al., 1997), reduced performance, decreased mental agility (Alward & Monk, 2003).

  21. Circadian Rhythms • Fatigue = impair memory, vigilance, reaction time, and communication = cyclic reductions in alertness and performance (Howard et al., 2002). • Internal body clock – external world (zeitgebers) • High activity during the day – low activity during the night • Human race is diurnal • Health problems (Crofts, 1999), negative effects: for the individual & the work place – decreased alertness & reduced job performance – affect the quality of care (Koller, 1996; Brown & Erkes, 1998) • Optimum mental performance level (2-4pm) and maximum general awareness is between (1-7pm. Performance levels are lowest between 3.30 – 5.30am (Coffey et al., 1998)

  22. Sleep Disorders (i) • Lack of sleep (Coffey et al., 1998) • Sleep disorder – tiredness – reduced functional capacity • Functional capacity may be halved after 24 hrs and after 48 hrs is at its lowest • Complex decisions (Akerstedt, 1999) though short term memory recall is not effected (Allen, 1999) • Sleep deprivation – disrupt the circadian rhythm – forces the body to function at night despite signals (i.e. Decreased body temp. & increased melatonin (Hughes & Stone, 2004)

  23. Sleep Disorders (ii) • Sleep quantity and sleep quality affected especially with night work • Daytime sleep not as deep or refreshing • Worse when room is not quite, not dark and not comfortable • Sleep quantity: Night shift (4-6 hrs) – Day shift (7.5 hrs) – Evening (8.5 hrs) • Sleep quality: day sleep – less deep sleep (stage 3 – 4); Rotating shift < Permanent shift • Sleep deprivation of 24 hours affect performance level (blood alcohol levels of 0.10%) (Dawson & Reid, 1997). Mature vs young night shift workers (Reid & Dawson, 2001).

  24. Night shift related fatigue and sleep difficulties (Bonnet, 2000; Harrison & Horne, 2000) Negative mood Sleep loss and fatigue Lack of innovation and creativity Increased distractability Inability to deal with unexpected events Inability to deviate from previous problem-solving strategies Unreliable temporal memory Impaired language skills Motor skill performance can be impaired (Eastridge et al., 2003; Grantcharov et al., 2001) Skill error increase (Taffinder et al., 1998) Skills required when dealing with violence & aggression Good attitude Observation skills – verbal & non-verbal skills Risk Assessment skills Communication skills Listening skills (active listening) Active listening skills Emotional intelligence – self-monitoring Positive regard Quick and empathic decision making skills Assertiveness skills Team coordination skills Coaching skills Limit settings Motor skills Offer choices and optimism Restraining skills Debriefing skills The Combination of Night Shift Nursing with Aggression & Violence

  25. Under-Reporting of Violence • Insufficient post-incident support(Pai & Lee, 2011; Kwok et al., 2006; Kamchuchat et al., 2008) • Stigma of victimisation(Hoff, 1992) • Accepted as a hazard of the profession(Daldt, 1981); part of the job (Poster, 1996; Prins, 1999) • Resistance from hospital administrators(Lanza, 1991) • Peer nursing pressure(Kinross, 1992) • Poor or ineffective reporting mechanisms (Lyon et al., 1981; Pearson et al., 1986; Silver & Yudofsky, 1987; Lanza, 1988; Monahan, 1989) • Lack of support from organisation (Paterson et al., 1999)but staff wassupported by their immediate nursing colleagues(McGeorge et al., 2000) • Lack of institutional reporting policies, employees beliefs and concerns (Sofiel & Salmond, 2005); Ferns, 2005; May & Grubbs, 2002, US Dept of Labor, 2008)

  26. Recommendations • Managment awareness – planning shift schedules – aware of biological rhythms. • Regular medical screening & breast screeing for night female nurses over 40 years of age • For health reasons – option to day work – option to night work • Critical incident stress debriefing or therapy • Training & Re-organisation of the ward routine (McGeorge et al., 2000) • Increasing face-to-face contact • Improving information sharing • Interaction with staff and patients • A significant amount of workplace aggression is preventable (DelBel, 2003). Education programs for nurses on fatigue and night work (Circadian Techologies, 2004) • Violence prevention programs (Kindy, 2005; Anderson & Parish, 2003; Gilmore-Hall, 2001; McPhaul & Lipscomb, 2008; US Dept of Labor, 2008)

  27. Conclusion • Link = human interaction & violence • Less incidents during the night – atmosphere tend to be more quiter • The organisation of ward routine • Staff-patient interaction = associated with violence • Good practioner during day not necessarily mean good practitioner during the night.

  28. Final thought...... ‘THE BEST FIGHTER IS NEVER ANGRY’ ................ Lao Tzu ‘but never tired ’.......

  29. THANK YOU

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