The nature and extent of aggression in nurses' clinical settings

397 Pages·2014·16.98 MB·English

THE NATURE AND EXTENT OF AGGRESSION IN NURSES'
CLINICAL SETTINGS
by
PO'
Gerald A Farrell
RMN RGN Dip N Cert Ed MSc
Submitted in fulfilment of the requirements for the degree of
Doctor of Philosophy
University of Tasmania
September, 1996
(ut
ABSTRACT
The concern raised in recent journal articles, reports and books
about the level of aggression within nursing was the impetus for this
study. Up until the last couple of decades the literature on
aggression among health service institutions was sparse. The few
nursing studies that are available on aggression deal with the extent
and effect of patient aggression on nurses. But not all aggression is
patient initiated. A few recent reports speak of horizontal violence, ie,
the idea that staff can be aggressive towards each other.
Understanding the extent of occupational aggression for nurses
whether patient or colleague initiated is thus an imperative research
agenda.
A total of 299 nurses were asked for their views on the extent and
nature of aggression at their work. Three main issues were
addressed. First nurses' understanding of the term aggression was
explored. Second, the nature and extent of aggression from patients
and others to nurses and vice versa was determined. Third, causal
relationships among variables were sought.
Two contrasting methodologies were employed in the study. First,
individual nurses (n = 29) from a variety of work settings were asked
about their experiences of aggression in the clinical setting. This was
essentially a qualitative study and it raised a number of important
insights regarding nurses' understanding of the term aggression and the
extent of the overall problem of aggression vis-a-vis patients, nurses and
others. Because of the small sample size, it was felt unwise to
extrapolate the findings to other similar contexts. Therefore,sa second
study was conducted - Phase 2 - in which the views of 270 nurses were
canvassed. As well as completing a questionnaire respondents were
asked to view a short video of an encounter between two nurses. This
enabled cause and effect relationships between hierarchy and blame
placement to be determined through a survey-embedded experiment.
Additionally, structural equation modelling was used to try an account for
why aggression persists.
The main findings can be summarised thus: First, nurses' understanding
of the term "aggression" encompasses a range of behaviours and
attitudes that can be conceptualized along three dimensions: physical-
verbal; active-passive; and direct-indirect. In practical terms, this
aggression was played out in such behaviours as rudeness, abusive
remarks, undermining each other's ideas, refusing to help when needed
and, more rarely, actual physical threat and assault. Much of the
aggression can be seen as colleagues' failure to play by the relationship,
rules of work. Second, the majority of respondents at Phase 1 indicated
that aggression from colleagues is a major concern for them. Third, this
view was largely confirmed in the lager sample at Phase 2. Taken
together, colleagues, doctors, and non-nurse managers come under fire
in many different work settings. Fourth, female and male nurses had
similar views about the level of colleague aggression towards them.
However, following colleague aggression, women were more concerned
about aggression from patients' relatives and doctors, men had most
trouble dealing with the aggression from their nurse managers. Fifth,
nurses' reactions to aggression can be seen in terms of three main
response patterns: a stress response, an anger response, and a
reflective response. Sixth, there was support for thinking that aggression
among nurses is situated within a culture that subscribes to the notion of
a "task/time" imperative. Seventh, there was little support for the view
that hierarchy influences blame placement preferences for deciding who
should be blamed for an incident. However, the Level-2 nurse attracted
more blame than either the Level-1 or the Level-3 grade for reacting
aggressively towards a colleague who was late. It would appear that the
Level-2 grade of nurse has a credibility gap vis-a-vis fellow colleagues.
Eight, there was tentative support for the notion that aggression, once
begun, may be self perpetuating. Ninth, overall, the results point to a
worrying level of nurse-on-nurse aggression in the clinical setting.
iv
DECLARATION
I certify that this Thesis contains no material which has. been
accepted for a degree or diploma by the University or any other
institution, except by way of background information and is duly
acknowledged in the Thesis, and to the best of my knowledge and
belief no material previously published or written by another person
except where due acknowledgment is made in the text of the Thesis.
Gerald Farrell
AUTHORITY OF ACCESS
This thesis may be made available for loan and for limited copying in
accordance with the Copyright Act 1968.
J
7
9r)-.-f--1/4Ai\
Gerald A Farrell
vi
ACKNOWLEDGMENTS
There are many people responsible for making this project possible.
Firstly, I'd like to thank Professor Wolfgang Grichting for his support
and wise counsel and who continued to act as my principal
supervisor after he moved job and state half-way through the study.
Vaughan Bowie contributed much too. His generosity in passing on
information and comments at different stages throughout the study
was greatly appreciated. John Carr, in his emissary role, helped
enormously during the numerous data collection visits to the hospital.
Thanks also to Janet Patford for "holding the fort". To the
respondents from the university and the hospital who gave me their
time so generously, and to the nurse managers who allowed ready
access to their staff, thank you. I am most grateful to those
colleagues who without solicitation kindly gave me articles because
they thought they might be useful, and to the many others who,
despite having their own busy agendas, showed interest in the
project's progress. It is colleagues like these that help make my work
"good". And lastly, a special thanks goes to my wife-and children.
Their forbearance and indulgence helped me see the project through.
vii
TABLE OF CONTENTS
ABSTRACT ii
ACKNOWLEDGMENTS vii
LIST OF TABLES xiv
LIST OF FIGURES xvii
CHAPTER ONE: INTRODUCTION
1.1 The problem 1
1.2 The nursing context: background factors 3
1.3 Significance of the study 6
1.4 Study overview 12
CHAPTER TWO: THE CONCEPT OF AGGRESSION
2.1 Introduction 14
2.2 Aggression: an etymological perspective 14
2.3 Definitions of aggression 15
2.4 Aggression: the scientific perspective 19
2.5 Aggression, assertion and passivity 28
2.6 The need to express aggression 30
2.7 Aggression in women and men 35
2.8 The nursing perspective on aggression 43
2.8.1 The incidence of aggression in nursing 44
2.8.2 The effect of aggression on nurses 48
2.8.3 The management of aggression 51
2.8.4 Horizontal violence 54
2.9 Conclusion 56
2.9.1 Introduction to Phases 1 and 2 of the study 58
CHAPTER THREE: PHASE 1: AGGRESSION IN NURSING -
NURSES' VIEWS
3.1 Introduction 61
viii
3.2 A method for finding out: grounded theory 62
3.3 University-based nurses' opinions of aggression in
the clinical setting: questionnaire results 64
3.4. Interviews with university nurses 65 •
3.5 Preliminary analysis of interviews with university
nurses 66
3.5.1 Professional terrorism 70
3.5.1.1 Aggression: direct and indirect
dimensions 71
3.5.1.2 Aggression: active and passive
dimensions 72
3.5.1.3 Aggression: physical and verbal
dimensions 74
3.6 Interviews with clinical nurses 75
3.7 Female and male views 79
3.8 Conceptualizing aggression in the clinical setting 81
3.8.1 Typologies of aggression 81
3.8.2 Aggression defined 84
3.8.3 Nurses' aggression as an instance of
rule breaking 85
CHAPTER FOUR: WHY DON'T NURSES PULL TOGETHER
MORE?
4.1 Introduction 89
4.2 Nursing as an oppressed discipline 89
4.3 Disenfranchising work practices 94
4.4 Clique formation 102
4.5 Nursing as a low-status profession 103
4.6 Aggression breeds aggression 106
4.7 The "response" of managers 109
4.8 "Nasty" colleagues 115
4.9 Conclusion 118
CHAPTER FIVE: THE PROS AND CONS OF
AGGRESSION IN THE WORKPLACE
5.1 Introduction 123
ix
5.2 Is conflict between workers necessarily bad? 123
5.3 Costs and benefits of staff-on-staff aggression 128
5.4 Keeping it in perspective: conflict in nursing
compared to other work situations. 133
5.5 Conclusion 135
5.6 Conclusion:Phase 1 135
5.6.1 Theoretical insights 136
5.6.2 The case for a larger sample 138
CHAPTER SIX: METHODOLOGICAL RAPPROCHEMENT

6.1 Introduction 141
6.2 The pros and cons of a positivistic/scientific

perspective 141
6.3 The pros and cons of an alternative perspective to

scientific notions of knowledge 150

6.4 The case for a middle-way 155
CHAPTER SEVEN: PHASE TWO - THE LARGER SAMPLE
PERSPECTIVE
7.1 Introduction 161
7.2 Overall research design 161
7.3 The major areas for further investigation 164
7.4 Recruitment of subjects 174
7.5 Sample characteristics 178
CHAPTER EIGHT: THE NATURE AND EXTENT OF
AGGRESSION IN NURSES' CLINICAL
SETTINGS
8.1 Introduction 183
8.2 Development of questionnaire items 184
8.3 Data analysis and results 190
8.3.1 Stability of nurses' responses 191
8.3.2 Nurses' experience of aggression 191
8.3.3 The most distressing "type" of aggression
to deal with 192
8.3.4 Nurses' current experience of aggression 196