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Violence experienced by registered nurses working in hospitals: an evaluation study

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Violence experienced by registered nurses working in hospitals: an evaluation study

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VIOLENCE EXPERIENCED BY REGISTERED NURSES WORKING IN
HOSPITALS: AN EVALUATION STUDY
by
Susan M. Holland

___________________________________________________
A Dissertation Presented to the
FACULTY OF THE USC ROSSIER SCHOOL OF EDUCATION
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
DOCTOR OF EDUCATION

December 2017

Copyright 2017 Susan M. Holland
2
Acknowledgements
This Dissertation is dedicated to my children, Alexandra and Teagan for their love
and support and who inspire me to be a better person. I would like to thank my dissertation
committee of Kimberly Hirabayashi, PhD, Helena Seli, PhD and Jennifer P. Stevens, MD for
their continued support and encouragement. I would also like to acknowledge nurses and all
healthcare professionals who dedicate themselves to caring for others.

3
Table of Contents
List of Tables 7
List of Figures 8
Abstract 10
Chapter 1: Introduction 11
Introduction to the Problem of Practice 11
Organizational Context and Mission of Proposed Project Site 11
Organizational Performance Goals 12
Related Literature 12
Importance of the Evaluation 13
Description of Stakeholder Groups 14
Stakeholder Group for the Study 15
Stakeholders’ Performance Goals 16
Purpose of the Project and Project Questions 16
Methodological Framework for the Project 17
Definitions 18
Organization of Project 19
Chapter 2: Review of Literature 21
Violence Experienced by Registered Nurses 21
The Hospital 21
The Registered Nurse (RN) Working in the Hospital 22
Violence in the Hospital 23
Outcomes of Violence Experienced by the RN 23
Analysis of the Problem from the Lens of Learning 24
Conceptual Framework 24
RN Knowledge, Motivation and Organization Influences 27
Knowledge and Skills 27
Knowledge types 27
RN knowledge influences 28
Declarative knowledge influences 29
Procedural knowledge influences 29
Metacognitive knowledge influence 1 31
Metacognitive knowledge influence 2 31
Motivation 32
Emotions: fear and anxiety 33
Self-efficacy 36
Registered Nurses’ self-efficacy 36
Organizational Influences 38
RN organizational influences 38
Cultural model influence 1 38
Cultural model influence 2 39
Cultural setting influence 1 39
Cultural setting influence 2 40
Conclusion 41
Chapter 3: Methodology 43
Purpose of the Project 43
4
Research Questions 43
Gap Analysis Conceptual Framework 44
Participating Stakeholders 44
Survey Sampling Criterion and Rationale 45
Criterion 1 45
Criterion 2 45
Criterion 3 45
Survey Sampling Recruitment Strategy and Rationale 45
Data Collection and Instrumentation 46
Survey 47
Assessment of Knowledge Influences 50
Assessment of Motivational Influences 51
Assessment of Organizational Influences 51
Data Analysis 52
Validity and Reliability 53
Credibility and Trustworthiness 54
Ethical Considerations 55
Chapter 4: Results and Findings 57
Overview 57
Participating Stakeholders 57
Demographics 58
Results and Findings 62
Scope of the Problem 62
Assessment of Knowledge Influences 63
Assessment of Motivational Influences 68
Emotion 68
Coping 69
Self-Efficacy 71
Assessment of Organizational Influences 73
Conclusion 81
Chapter 5: Discussion and Organizational Recommendations 82
Introduction 82
Purpose of the Project 82
Discussion of Results and Findings 83
Major Themes 83
Lack of Reporting 83
Low Self-Efficacy 84
Limitations and Suggestions for Future Research 86
Recommendations for Practice 87
Knowledge Recommendations 87
Introduction 87
Conceptual Knowledge 89
Procedural Knowledge 90
Metacognitive Knowledge 1 91
Metacognitive Knowledge 2 91

5
Motivation Recommendations 91
Introduction 91
Emotions 95
Self-Efficacy 95
Organization Recommendations 96
Introduction 96
Cultural Model Influence 1 98
Cultural Model Influence 2 99
Cultural Setting Influence 1 99
Cultural Setting Influence 2 99
Integrated Implementation and Evaluation Plan 100
Implementation and Evaluation Framework 100
Organizational Purpose, Need and Expectations 101
Level 4: Results and Leading Indicators 102
External Leading Indicators 102
Internal Leading Indicators 103
Level 3: Behavior 106
Critical Behaviors 106
Required Drivers 108
Monitoring and Organizational Support 110
Level 2: Learning 110
Learning Goals 110
Program 111
Components of Learning 111
Declarative Knowledge 113
Procedural Skills 113
Attitude 113
Confidence 114
Commitment 114
Level 1: Reaction 114
Evaluation Tools 116
Prior to Attending Initial Program 116
Immediately Following the Program Implementation116
Delayed for a Period After the Program 116
Implementation
Data Analysis and Reporting 116
Concurrently and Ongoing 116
Summary 119
References 121
Appendix A: Survey Items 136
Appendix B: Information/ Facts Sheet for Exempt Non-Medical Research 140
Appendix C: Recruitment Letter 142
Appendix D: Pre-Test before Program 143
Appendix E: Immediate Evaluation Form after Program (Levels 1 and 2) 145
Appendix F: Delayed Evaluation- 6 months after Program 146
(Levels 1,2,3, and 4)
6
Appendix G: Annual Anonymous Survey of RNs 148
Appendix H: Sample Program Outline and Sample Agenda 149

7
List of Tables
Table 1: Stakeholders’ performance goals 16
Table 2: Assumed knowledge influences and assessment 32
Table 3: Assumed motivation influences and assessment 37
Table 4: Assumed organization influences and assessment 41
Table 5: Survey items and KMO influences assessed 48
Table 6: RN survey results of frequency of experiencing and reporting 64
aggression or physical violence by patients or visitors

Table 7: RNs’ reports of self-efficacy in regards to ability to de-escalate or 72
protect oneself

Table 8: RNs’ level of agreement with statements 76
Table 9: Summary of knowledge influences and recommendations 88
Table 10: Summary of motivation influences and recommendations 94
Table 11: Summary of organization influences and recommendations 97
Table 12: Outcomes, metrics, and methods for external outcomes 103
Table 13: Outcomes, metrics, and methods for internal outcomes 105
Table 14: Critical behaviors, metrics, methods, and timing for evaluation 107
Table 15: Required drivers to support critical behaviors 109
Table 16: Components of learning for the program 112
Table 17: Components to measure reactions to the program 115

8
List of Figures
Figure A: Problem of practice conceptual framework and the relationships 26
between knowledge, motivation, and organizational influences

Figure B: Race of the RNs in the study sample 59

Figure C: Location of the hospitals where RNs in the study sample work 59

Figure D: Educational preparation of RNs in the study sample 60

Figure E: Years of experience of RNs in the study sample 61

Figure F: Ages of RNs in the study sample 61

Figure G: Primary roles in organizations of RNs in the study sample 62

Figure H: RNs’ reported frequency of experiencing acts of aggression or 63
physical violence by patients or visitors

Figure I: RNs’ frequency of reporting incidents of aggression or physical 64
violence by patients or visitors

Figure J: Presence of a way to silently alert security about a safety threat in 65
work areas of RNs in the study sample

Figure K: RNs’ knowledge of existence of a formal process to report 65
aggression or physical violence by visitors at their workplace

Figure L: Major themes identified from narrative responses to question about 67
helping a novice nurse manage a situation when a patient or visitor became
aggressive and/or physically violent

Figure M: Major themes from narrative responses to question about emotion 69
s that the RNs in the sample feel when a patient or visitor becomes aggressive
or physically violent

Figure N: Major themes from narrative responses to question about how the 71
RNs in the sample cope following a situation when a patient or visitor becomes
aggressive or physically violent

Figure O: RNs’ reports of self-efficacy in regards to their ability to de-escalate 73
or protect oneself

Figure P:The percentage of RNs who reported having received training in each 74
Topic
9
List of Figures (continued)

Figure Q: RNs’ level of agreement with the statement, my organization takes 75
incidents of aggression or physical violence by patients or visitors seriously

Figure R: RNs’ level of agreement with the statement, my supervisor takes 76
appropriate action when a patient or visitor is physically violent towards me

Figure S: RNs’ level of agreement with the statement, I am encouraged to 77
complete hospital safety reports/ or some type of incident report whenever a
patient is aggressive or physically violent towards me

Figure T: Major themes identified from narrative responses to the question about 78
effectiveness of the approach from workplace in addressing issues of aggression
and/or physical violence

Figure U: Major themes identified from narrative responses to the question 80
about additional thoughts about the topic

Figure V: Sample of incident reporting tool 117

Figure W: Sample dashboard 118

Figure X: Sample update for a hospital newsletter 118

10
Abstract
The purpose of this study was to complete an exploratory evaluation of nurses’ experiences and
beliefs about violence in the workplace. The specific performance issue that was explored was
the violence experienced by Registered Nurses (RNs) while working in hospitals in
Massachusetts. The research questions included: 1) what was the nature of the RNs’ experiences
in aggression and/or physical violence while working in the hospital? 2) what were the barriers
for an organization to measure and evaluate these incidents? and 3) what were the
recommendations for the organizational practice? Clark and Estes’ (2008) gap analysis was used
and adapted to the evaluation model and implemented as the conceptual framework. Snowball
sampling resulted in a sample size of 254 individuals who completed electronic surveys. The
data collected included demographics, frequency of experiencing acts of aggression and/or
physical violence, frequency of reporting these incidents, and an assessment of the knowledge,
motivation, and organizational influences related this problem of practice. The data analysis was
both exploratory and descriptive and included coding of open ended responses to identify themes
and descriptive statistics. The two major findings were that there was a lack of reporting of these
types of incidents and there was low self-efficacy of RNs related to this problem of practice. The
recommendations for practice addressed the knowledge, motivation and organizational
influences using Clark and Estes (2008) framework. An integrated implementation and
evaluation program for organizations was then described using the New World Kirkpatrick
Model (2016) as a framework.

11
CHAPTER 1: INTRODUCTION
Introduction of the Problem of Practice
The problem of practice and focus of this paper is the violence experienced by Registered
Nurses (RNs) working in hospitals from patients and visitors. This is a problem because many
healthcare workers in hospitals describe experiencing at least one physical assault during the past
year while at work and most of these assaults are not reported to hospital administrators (Erikson
& Williams-Evans, 2000; Hodgson, Reed, Murphy, Lehmann & Warren, 2004; Kvas & Sejack,
2014). There can be significant physical and psychological harm experienced by these healthcare
workers who are victims of violence, resulting in lost work time, injuries, psychological trauma
and disability (National Institute for Occupational Safety and Health (NIOSH), 2002).
Organizational Context and Mission of Proposed Project Site
The proposed project sites are hospitals within the state of Massachusetts. There are 78
acute care hospitals licensed in the state of Massachusetts (Division of Health Care Facility
Licensure and Certification, 2016). In 2015, the U.S. Census Bureau estimated that the
population in Massachusetts was 6,794,422. Although the population growth is slower than
many other parts of the country, compared to other states, Massachusetts has the third highest
population density with 864.8 persons per square mile (University of Massachusetts, 2016). It is
important to note that the percentage of persons 65 years of age and over is predicted to continue
to grow and this may indicate a greater need for healthcare services in the future and fortunately
Massachusetts continues to lead the nation with 96.3% of citizens having health insurance
(University of Massachusetts, 2016).
12
The Massachusetts Hospital Association (MHA) (2016) represents most of the hospitals
within the state of Massachusetts and explains that the basic mission of its members is caring for
people. The American Nurses Association ([ANA], 2016) explained that
Nursing is the protection, promotion, and optimization of health and abilities, prevention of
illness and injury, facilitation of healing, alleviation of suffering through the diagnosis and
treatment of human response, and the advocacy in the care of individuals, families, groups,
communities, and populations (ANA, n.p.).

Organizational Performance Goals
In 2013, Senate Bill Number 1313 was filed in Massachusetts to petition for the adoption
of “An Act requiring health care employers to develop and implement programs to prevent
workplace violence” (2013). The last action on this bill was taken in April 2016 when the bill
was referred to the Massachusetts Senate Committee on Ways and Means.
A stakeholder goal that reflects the problem of violence experienced by RNs in hospitals
is that by December 2018, all RNs working in hospitals in Massachusetts will articulate at least
three interventions they may use when confronted by situations of verbal or physical violence. A
global goal is that all hospitals in Massachusetts to successfully implement a program to prevent
workplace violence by December 2017 (see Table 1).
Related Literature
Workplace violence has been defined by the NIOSH (2002) as “violent acts (including
physical assaults and threats of assaults) directed toward persons at work or on duty” (p.1).
Nachreiner, Gerberich, Ryan and McGovern, (2007) found that verbal abuse was the most
frequently observed type of violence in their study. Hostility and verbal threats were found to be
among the themes describing the verbal abuse experienced by nurses (Jackson, Hutchinson, Luck
and Wilkes, 2013). Hodgson, et al. (2004) described physical aggression as “forceful, hostile or
aggressive behavior that may or may not cause harm” (p. 368).
13
Hospitals operate twenty-four hours a day and Gerberich, et al. (2005) described how
environmental factors correlate with the risk of violence including how “the odds of assault were
doubled when lighting was less bright than daylight” (p.708). In addition, there can be long waits
for patients to be seen in areas such as an emergency department which can increase the
frustration experienced by patients and their families (US Department of Justice, 2002).
Importance of the Evaluation
The problem of violence experienced by RNs working in hospitals is important to solve
for a variety of reasons. There can be significant physical and psychological harm experienced
by these healthcare workers who experience violence, including physical injury, disability,
psychological trauma or death (National Institute for Occupational Safety and Health (NIOSH),
2002). Violence toward healthcare workers may result in lost work time, decreased employee
morale and increased employee turnover (NIOSH, 2002; O’Brien, Tariq, Ashraph and Howe,
2014).
Healthcare workers who experienced violence were found to be at greater risk for
developing work related stress in the future (Magnavita, 2014). Yang, et al (2012) found similar
results demonstrating that exposure to violence resulted in increasing symptoms of
musculoskeletal disorders and somatic symptoms such as having trouble sleeping and fatigue.
Allareddy, et.al. (2007) reported that the median number of missed work days as the result of a
violent event was four and employees missed at least one full day of work in 32.8% of the cases.
The effects of violence experienced by RNs in the workplace is a problem that must be addressed
as it can result in substantial psychological and/or physical injury and can have a financial
impact upon organizations from lost work time and employee (Magnavita, 2012; Miranda,
14
Punnett & Gore, 2014; Yang, et al, 2012; NIOSH, 2002; O’Brien, Tariq, Ashraph and Howe,
2014).
Description of Stakeholder Groups
Registered Nurses (RNs) are specially trained individuals who are licensed within the
state of Massachusetts and are responsible for “providing nursing care, health maintenance
teaching, counseling, planning and restoration for optimal functioning and comfort of those they
serve” (Massachusetts Board of Registration in Nursing, 244 CMR 3.01).
In 2016 there were 115,342 RNs licensed within the state of Massachusetts
(Massachusetts Board of Registration in Nursing, 2017). These RNs work in a variety of settings
such as in hospitals, school settings, and visiting patients’ homes. Because of their responsibility
to care for an assigned patient or group of patients typically for an eight or 12 hour shift, RNs in
hospitals have a significant amount of patient and family contact and may be exposed more than
other healthcare workers to verbal or physical violence.
Another stakeholder group includes hospital administrators who are responsible for
ensuring that patients are receiving high quality care, monitoring finances to provide this high
quality care at the lowest cost and providing resources and education to hospital staff so they
may provide high quality patient care safely. Hospital administrators are also responsible for the
goal of decreasing lost work days due to injury from a financial perspective initially. If hospital
administrators do not recognize potential high risk areas that may cause injury to employees,
such as violence experienced by RNs, then there may be an increase in employee turnover,
decreased employee morale and possibly impact the quality of care that patients receive.
Physicians in hospitals are a stakeholder group as well. These physicians are licensed in
the state of Massachusetts to practice medicine and work in hospitals. Physicians are another
15
part of the healthcare team in a hospital and have a significant amount of direct contact with
patients and families. This group could also benefit from the achievement of the goal of by
December 2018, all RNs working in hospitals in Massachusetts will articulate at least three
interventions they may use when confronted by situations of verbal or physical violence because
of their close working relationship with RNs.
Stakeholder Group for the Study
The primary stakeholder group members are RNs who work in hospitals in
Massachusetts. The reason that the primary stakeholder group chosen is RNs working in
hospitals in Massachusetts versus RNs working at one specific hospital or hospital system is
because of concerns regarding confidentiality and potential perceived conflict of interest because
of this principal investigator’s current role within a hospital in Massachusetts. However, it is
anticipated that the results of this study will be beneficial for all hospital administrations in
Massachusetts.
Although a complete analysis would involve all stakeholder groups, for practical
purposes, only one stakeholder group will be the focus for this study. The state of Massachusetts
was chosen for convenience and is of interest to the principal investigator. In addition, the
Massachusetts Occupational Injuries and Illnesses Annual Report (2015) found that by
occupation, Registered Nurses had the highest number of nonfatal occupational injuries and
illnesses that involved Days Away from Work (DAFW). Registered Nurses in Massachusetts
accounted for 1,720 work related injuries or illnesses that resulted in DAFW which is an increase
of 18% compared with data from 2014 when there were 1,450 work related injuries and illnesses
(Massachusetts Occupational Safety and Health Statistics Program, 2015; Massachusetts
16
Occupational Safety and Health Statistics Program, 2014). Table 1 describes the Organizational
Mission, Global Goal and Stakeholders’ Performance Goals.
Stakeholders’ Performance Goals
Table 1
Organizational Mission, Global Goal and Stakeholder Performance Goals
Organizational Mission
The American Nurses Association (2016) defines nursing as “the protection, promotion, and
optimization of health and abilities, prevention of illness and injury, facilitation of healing,
alleviation of suffering through the diagnosis and treatment of human response, and advocacy in
the care of individuals, families, groups, communities and populations” (ANA, n.p).
Global Performance Goal
By December 2018, all hospitals in the state of Massachusetts will implement a violence
prevention and management program for healthcare workers
Stakeholder Performance Goal
The goal that reflects the problem of violence experienced by RNs in hospitals is that by
December 2018, all RNs working in hospitals in Massachusetts will articulate at least three
interventions they may use when confronted by patients or visitors who are aggressive or
physically violent
Registered Nurses Working
in Hospitals in Massachusetts
Hospital Administrators in
Massachusetts
Physicians Working in Hospitals
in Massachusetts
By December 2018, all
Registered Nurses working in
hospitals in Massachusetts
will articulate at least three
interventions they may use
when confronted by patients
or visitors who are
aggressive or physically
violent
By January 2018, Hospital
Administrators in
Massachusetts will implement
a violence prevention program
for all healthcare workers in
their hospitals, in regards to
how to respond when patients
or visitors are aggressive or
physically violent.
By December 2018, all
physicians working in hospitals
in Massachusetts will articulate
at least three interventions they
may use when confronted by
patients or visitors who are
aggressive or physically violent

Purpose of the Project and the Project Questions
The purpose of this project was to complete an exploratory evaluation of nurses’
experiences and beliefs about violence in the workplace. The specific performance issue that
17
was explored was the violence experienced by Registered Nurses while working in a hospital in
Massachusetts. The methodology and analysis will focus on knowledge, motivation and
organizational elements related violence experienced by RNs working in hospitals in
Massachusetts. The stakeholders to be focused on in this analysis are Massachusetts RNs
working in hospitals. While a complete performance evaluation would focus on all stakeholders,
for practical purposes the stakeholder group to be focused on in this analysis includes RNs who
are licensed in Massachusetts who work in hospitals.
The questions that guided this evaluation study addressing the knowledge and skills,
motivation, and organization elements for RNs who are licensed in Massachusetts and work in
hospitals were:
1. What is the nature of the RNs’ experiences in aggression and/or physical violence while
working in the hospital and how are these experiences shaped by knowledge, motivation
and organizational influences?
2. What are the barriers for an organization to measure and evaluate incidents of aggression
or physical violence by patients or visitors towards nurses?
3. What are the recommendations for organizational practice in the areas of knowledge,
motivation, and organizational resources?
Methodological Framework for the Project
This was a primarily quantitative study with some open-ended items. An embedded
mixed methods approach was used to explore the research questions to gather data about the
knowledge, motivation and organizational influences of RNs who work in Massachusetts
hospitals in regards to patients or visitors who become aggressive and/or physically violent.
18
Clark and Estes’ (2008) gap analysis was used and adapted to the evaluation model and
implemented as the conceptual framework. The gap analysis is a systematic, analytical method
that helps to clarify organizational goals and identify the knowledge, motivation and
organizational influences related to a problem (Clark & Estes, 2008). Using surveys and open-
ended questions within the survey, Registered Nurses’ experiences of aggression and/or physical
violence by patients or visitors while working in a hospital was assessed as well as knowledge
and organizational influences. In addition, motivational influences were assessed using these
surveys including open-ended questions specifically in regards to emotions and self-efficacy.
Research-based solutions are recommended and evaluated in a comprehensive manner in
Chapter 5 (Clark & Estes, 2008; Jha, 2008; Lemieux-Charles & Champagne, 2008; Schwandt,
2012).
Definitions
The operational definitions in regards to this problem of practice include workplace
violence and the types of workplace violence and then further broken down into aggression
and/or physical violence as described below:
Workplace Violence: OSHA (2016) defines workplace violence as “any act or threat of physical
violence, harassment, intimidation, or other threatening disruptive behavior that occurs at the
work site. It ranges from threats and verbal abuse to physical assaults and even homicide” (n.p.).
The US Department of Justice and FBI (2002) presented four general types of violence
that may occur in the workplace:
1. TYPE 1: Violent acts by criminals who have no other connection with the
workplace, but enter to commit robbery or another crime
19
2. TYPE 2: Violence directed at employees by customers, clients, patients,
students, inmates, or any others for whom an organization provides
services.
3. TYPE 3: Violence against coworkers, supervisors, or managers by a
present or former employee
4. TYPE 4: Violence committed in the workplace by someone who doesn’t
work there, but has a personal relationship with an employee – an abusive
spouse or domestic partner (US Department of Justice & FBI, 2002).
Aggression: For the purposes of this study, aggression included verbal communication
that was perceived as hostile, angry, threatening or demeaning and threatening behavior
such as the act of punching a wall.
Physical Violence: Physical violence included the actual act of / or attempt to hit, punch,
slap, push, kick, spit upon, scratch, bite, assault with a weapon, sexually assault, squeeze
tightly, throw an object and/or strangle another individual.
Organization of Project
Five chapters were used to organize this study. This first chapter introduced the problem
of practice of violence experienced by RNs working in Massachusetts hospitals, the global
mission of nursing, goals and stakeholders as well as the review of the evaluation framework.
This chapter also provided the reader with the key concepts and terminology commonly found in
a discussion about workplace violence and the problem of violence experienced by RNs working
in Massachusetts hospitals. Chapter Two provides a review of literature surrounding the scope of
the study. Topics of the hospital environment, role of the RN in the hospital, the culture of the
nursing profession, violence in the hospital and the potential outcomes for RNs who experience
20
violence while working in the hospital are included. Chapter Three describes the knowledge,
motivation and organizational elements that were examined in the study drawing upon a
conceptual framework as well as the methodology when it came to the choice of participants,
data collection and analysis. In Chapter Four, the data and results are described and analyzed.
Chapter Five provides recommendations for practice, based on data and literature as well as
recommendations for an implementation and evaluation plan.
21
CHAPTER 2: REVIEW OF LITERATURE
Violence Experienced by Registered Nurses
Chapter Two outlines the problem of violence experienced by Registered Nurses (RNs)
from patients or visitors. The first section focuses on historical information about workplace
violence as well as the unique circumstances of the hospital environment. The second section
describes the role of the RN in hospitals including some aspects of the professional culture. The
third section examines the outcomes of RNs who experience violence in the workplace. The
chapter ends with an analysis of teamwork from the lens of learning and motivation literature
utilizing the gap analysis dimensions of knowledge, motivation, and organization.
The Hospital
When exploring the problem of aggression or physical violence that may occur within the
hospital, it is essential to consider the environment of a hospital. Hospitals present a unique set of
circumstances in regards to the risk of violence. There is often unrestricted access to many areas
of a hospital for patients and visitors (US Department of Justice, 2002). Hospitals provide care
to patients who may be under the influence of drugs and alcohol which increases the risk of
violence (NIOSH, 2002). In their study about violence in healthcare settings, Ayranci,
Yenilmez, Balci and Kaptanoglu (2006) reported that the most significant factor found in relation
to violence toward healthcare workers was excessive wait times for patients. Another study
exploring rates of violence toward staff found that there was an association between
overcrowding in the emergency department and episodes of violence toward staff (Medley,
Morris, Stone, Song, Delmas and Thakrar, 2012).
In addition to the physical layout and structure of the hospital, there are many sensory
experiences that are unique to a hospital setting. Zampieron, Galeazzo, Turra and Buja (2010)
explained that the causes of aggression towards nurses are often situations such as the death of a
22
loved one, receiving bad news and experiencing long wait times. Assaults have been found to
occur more frequently when patients are not satisfied with the service that they are receiving
(Farrell, Shafiei & Chan, 2014).
The Registered Nurse (RN) Working in the Hospital
RNs practice in different areas of the hospital and each presents itself with factors that may
influence the risk of experiencing aggression or physical violence. Alexander, Fraser and Hoeth
(2004) explored occupational violence in an Australian healthcare setting and found that nurses
experienced more occupational violence than other healthcare professionals. In a hospital, RNs
may work in different areas depending upon their training and interest such as the emergency
department, an inpatient unit or the critical care unit.
A study by Arnetz, Hamblin, Ager, Aranyos, Upfal, Luborsky, Russell and Essenmacher
(2014) found that the probability of violence occurring in a hospital was highest in psychiatric
units where patients who are experiencing an acute episode of a mental illness are cared for.
Duhart (2001) found that the rate of assault on mental health workers was the highest of any
occupation other than law enforcement. The NIOSH (2002) explained that among healthcare
workers in hospitals, nurses are among those to be at greater risk of being victims of violence
because of the amount of direct contact they have with patients.
Although there is data to demonstrate that nurses are experiencing aggression and/or physical
violence, there continues to be significant underreporting of these incidents by RNs (McKoy and
Smith, 2001; Ayranci, Yenilmez, Balci and Kaptanoglu, 2006). Erickson and Williams-Evans
(2000) explored the attitudes of emergency nurses regarding patient assaults and found that many
nurses viewed these occurrences as being “part of the job.” Similarly, Nachreiner, Gerberich,
23
Ryan and McGovern (2007) found in their study that many nurses also believed that patient
assaults are a consequence of the job.
Violence in the Hospital
Violence not only includes physical acts inflicted upon another individual, but also the words
that are used toward another individual and behaviors that are intimidating. In a study regarding
perceived aggression towards nurses, Zampieron, Galeazzo, Turra and Buja (2010) found that
the majority of aggression towards nurses was in the form of verbal abuse.
Physical violence may or may not cause injury and includes an array of examples that may
occur in a hospital toward a nurse. Physical violence may include the use of physical force such
as slapping, pushing, hitting, punching and grabbing (Kvas & Sjeak, 2014; Farrell, Shafiei and
Chan, 2014). Alexander, Fraser and Hoeth (2004) found that 34% of the nurses in their study
reported that they have experienced physical violence in the workplace. Healthcare workers were
assaulted most frequently by patients while visitors were the next most common assaulters
(Hodgson, et al, 2004).
Violence toward healthcare workers is underreported to hospital administration (McKoy &
Smith, 2001). In one study, 72% of staff who were victims of verbal or physical violence did not
report it (Allareddy, et al, 2007). In another study, only 29% of those who were physically
assaulted reported these incidents (Erickson & Williams, 2000). The reasons why violence is
underreported by healthcare workers included feeling as though nothing would change and the
fear of losing ones’ job (Kvas & Sejak, 2014).
Outcomes of Violence Experienced by the RN
The immediate outcome of violence experienced by the RN may include a physical injury
requiring medical attention, a physical injury that the RN does not think requires immediate
24
medical attention and/or the feelings of anxiety and fear (Kowalenko, Gates, Gillespie, Succop
and Mentzel, 2013; Hodgson, et al., 2004). Emergency department workers who experienced
violence were found to suffer from injuries, acute stress and lost productivity (Kowalenko,
Gates, Gillespie, Succop & Mentzel, 2013). Miranda, Punnett and Gore’s (2014) prospective
study of clinical staff in nursing homes reported that 55% of respondents experienced at least one
physical assault within three months prior to the survey. They found that the more often a staff
member was assaulted, the more reports of musculoskeletal pain the staff member experienced.
Patients and their families also suffer from the consequences of physical violence toward
healthcare workers. Because of concerns about safety, there have been changes to service
delivery because of experiences of violence in the healthcare setting, such as not making patient
appointments after usual business hours or nurses only making home visits to known patients
(Alexander, Fraser & Hoeth, 2004; Farrell, Shafiei & Chan, 2014). Gates, Gillespie and Succop
(2011) found that after a nurse experiences a violent event, they often demonstrate decreased
productivity which may negatively impact communicating with patients and families and their
ability to offer emotional support.
Analysis of the Problem from the Lens of Learning
Conceptual Framework
A conceptual framework describes what is happening in terms of key factors, beliefs,
assumptions and variables in regards to a certain phenomenon (Maxwell, 2013). The content of
the conceptual framework is supported through literature, tailored to a specific problem of
practice, may be discipline specific and guides the research design (Merriam & Tisdell, 2009;
Maxwell, 2013).
25
The phenomenon or problem of practice is aggression and/or physical violence
experienced by Registered Nurses (RNs) working in hospitals. The stakeholder goal is that by
December 2018, RNs working in hospitals in Massachusetts will articulate at least three
interventions they may use when confronted by situations of aggression and/or physical violence.
The specific analytic approach is the Gap Analysis Conceptual Framework (Clark & Estes,
2008). According to Clark and Estes (2008), performance gaps fall into one of three main
categories: stakeholder knowledge, stakeholder motivation or organizational factors (KMO). In
order to improve performance or implement a solution, there must be a thorough understanding
of the causes of a problem of RNs not knowing three interventions that they can use when
confronted by verbal or physical violence in the hospital. Within Figure A, the relationships
between KMO are described.

26

Figure A. Conceptual Framework
27
RN Knowledge, Motivation and Organization Influences
Knowledge and Skills
This section will focus on knowledge-related influences that are pertinent to the
achievement of the stakeholder goal of RNs being able to describe what to do when a patient or
visitor is aggressive and/or physically violent. This analysis will include reviewed literature in
terms of the type of knowledge that is being described. Understanding the different knowledge
types related to this problem of practice will help to guide this evaluation study.
Knowledge types. The different knowledge types that will be analyzed include:
conceptual knowledge, procedural knowledge and metacognitive knowledge. Declarative
knowledge includes the information that one must know in order to solve a problem or be
successful in a task and consists both of factual knowledge and conceptual knowledge
(Krathwohl, 2002; Schraw, Veldt, & Olafson, 2009). Declarative knowledge has also been
shown to be important when making complex decisions (Gupta, Duff, Denburg, Cohen, Bechara,
& Tranel, 2009). Gunzelmann, Gluck, Moore and Dinges (2010) found that access to one’s
declarative knowledge significantly decreases when one is sleep deprived. This needs to be
considered for nurses working overnight in hospitals as it may affect performance.
Factual knowledge consists of details, terminology, facts, or elements that must be
understood to perform a role, solve a problem or complete a task (Rueda, 2011). An example of
factual knowledge may be a nurse reviewing the blood test results of a patient and knowing the
normal parameters. Conceptual knowledge consists of understanding classifications, models or
structures and the relationship that may exist between facts or ideas that are part of a larger
configuration (Krathwohl, 2002; Rueda, 2011). Conceptual knowledge is the knowledge that is
learned during nursing education about the normal parameters of blood results and
28
pathophysiology. Without the factual knowledge of what blood tests are abnormal and the
conceptual knowledge to be able to connect those results to the patient’s disease process, the RN
would not know to report this information to the physician. It is evident by this example that
declarative knowledge is important to performance outcomes in healthcare because if this
information is not shared in a timely manner to a physician, and a therapy is not prescribed, then
there may be a negative outcome for the patient.
Procedural knowledge is the knowledge of how to do something and when to do
something, often by understanding processes or algorithms (Krathwohl, 2002). An example of
procedural knowledge is the nurse knowing how to review the blood test results of a patient and
identify a relationship between abnormal blood results and the patient’s medical diagnosis which
may determine which course of action will be taken.
Metacognitive knowledge is having an awareness of one’s own cognition, knowledge of
one’s self and is an important component for strategic problem solving (Baker, 2006; Rueda,
2011). An example of metacognitive knowledge in the nursing profession is a nurse receiving a
verbal hand-off report from the off-going nurse about a patient and the nurse realizing that they
have not had a lot of experience performing a central venous catheter bandage change. By
understanding their own knowledge and experience, the nurse then seeks out the assistance of a
more experienced nurse to assist them with the bandage change. Although the nurse may know
“why” and “how” to do the bandage change, without this metacognitive knowledge of one’s
ability to perform this task, there could be the negative performance outcome of not completing
the bandage change correctly which ultimately could have negative consequences for the patient.
RN knowledge influences. The literature that will be examined is relevant to the
stakeholder group and the stakeholder goal of all RNs working in hospitals in Massachusetts will
29
articulate at least three interventions they may use when confronted by situations of aggression
and/ or physical violence. A description of each assumed knowledge influence with supporting
literature and methods of assessment will be shared. In the Conceptual Framework in Figure A,
knowledge influences literally rest upon organizational factors that will be described later in this
chapter.
Declarative knowledge influences. Declarative knowledge influences include both
factual knowledge and conceptual knowledge. One conceptual knowledge influence includes
RNs knowing what support or assistance is available to them within the hospital if a patient or
visitor becomes aggressive or physically violent. The support or assistance may come from
Public Safety/ Security or a fellow nurse or physician who inserts themselves into a conversation
that is becoming threatening or profanity laced. Welch (2008) explained that there are many
characteristics of patient behavior that may be considered possible predictors of violent behavior
such as appearing angry, talking loudly, using profanity, throwing or punching inanimate objects,
and using drugs or alcohol. Conceptual knowledge will also assist the nurse in determining
his/her course of action, for example he/she may try to de-escalate the situation him/herself or
contact Public Safety/ Security immediately for assistance.
Procedural knowledge influences. As the stakeholder group of focus, nurses need to
know how to protect themselves and others and respond to immediate threats to safety. These
steps may include having a co-worker assist during patient care to keep the patient and nurses
safe or even to have Public Safety/ Security present during patient care to keep the patient and
nurse safe. Other forms of support and assistance may include how to contact the Public Safety
Department/ Security to come to the unit. There are other environmental factors and steps to be
30
taken as a prevention strategy and when a situation occurs such as sufficient lighting, visible
security staff, and silent alarm systems (Welch, 2008).
Procedural knowledge is necessary for RNs to know how to recognize early signs of
agitation or hostility in others and either attempt to de-escalate the situation or ask for immediate
help from other supports. Nurses also need to know how to implement strategies that may de-
escalate a situation when a patient or visitor becomes verbally abusive, threatening or physically
violent. Specific strategies such as active listening, expressing concern for the individual and
body language have also been shown to help de-escalate situations (Welch, 2008). Mantzoukas
and Jasper (2008) described in general terms that the procedural knowledge of nurses as a
profession tends to be automated and occurs unconsciously in various complex situations. This
procedural knowledge is dependent upon an organizational cultural setting influence of
providing training to RNs in how to de-escalate an angry individual and how to respond to actual
physical violence.
The literature is mixed regarding the effectiveness of training in decreasing patient or
visitor assaults. Erickson and Williams-Evans (2000) found that nurses who attended an assault
prevention class were less likely to be assaulted while Farrell, Shafiei and Chan (2014) found
that attending aggression management training did not decrease the frequency of patient and
visitor assaults. Another study found that there was an increase in the number of incidents of
patient and visitor violence toward healthcare workers for those staff who had received
aggression training (Hahn, Muller, Kok, et al., 2013). These findings suggest that there should
be further examination into the research about the content and delivery of training to help
determine what may be most effective.
31
Metacognitive knowledge influence 1. The first metacognitive influence is that RNs
need to know how to reflect on this or her own practice after trying to de-escalate an aggressive
patient or visitor. RNs also need to reflect upon situations when physical violence occurs to
evaluate their own response to protect themselves and others, including seeking other support in
the hospital such as Public Safety Officers. This response is also being able to apply conceptual
knowledge of knowing when one can handle a situation themselves and when they may need
help. Mantesso, Petrucka and Bassendowski (2008) explained how reflective practice in addition
to peer feedback can be very effective in assessing nurses’ competence, strengths and areas for
development.
Metacognitive knowledge influence 2: The second metacognitive influence is that RNs
need to have self-awareness about how emotions that they may experience may influence their
own behavior when confronted by situations of aggression or physical violence. Rueda (2011)
explained that emotions impact whether one engages in choice, persistence and effort. Table 2
summarizes the assumed knowledge influences and the assessment of those influences.

32
Table 2
Assumed Knowledge Influences and Assessment
Assumed knowledge influence How will it be assessed?
Conceptual:
Nurses need to know what supports are
available to them if a patient or visitor
becomes aggressive or physically violent

Using an open-ended question within a
survey, assess the knowledge of nurses in
regards to managing a situation when a
patient or visitor is aggressive or
physically violent.

Procedural:
Nurses need to be able to implement
strategies that may de-escalate a situation
and/or respond when a patient or visitor
becomes aggressive or physically violent in
the hospital environment

Using open-ended questions within a
survey, ask nurses to describe the process
of managing a situation when a patient or
visitor is aggressive or physically violent.

Metacognitive:
Nurses need to know how to reflect on
their own practice both in de-escalating
situations and how effective their
interventions are when responding to
aggression or physical violence to protect
themselves and others.

Nurses need to have self-awareness about
how emotions that they may experience
may influence their own behavior when
confronted by situations of aggression or
physical violence

Using open-ended questions within a
survey, ask nurses to describe the process
of managing a situation when a patient or
visitor is aggressive or physically violent
and how they personally cope following a
situation when a patient or visitor was
aggressive or physically violent.

In a survey, using both fixed and open-
ended questions, ask nurses about how
they feel and cope when a patient or
visitor is aggressive or physically violent

Motivation
This is a literature review focuses on the motivation-related influences that are pertinent
to the achievement of the stakeholder goal. Eccles (2006) explained that there are different
factors that may influence the expectance-value model which includes an individual’s belief that
he/she can do a task and an individual’s desire to do that task. Motivation is necessary in
problem solving because unless individuals believe that their action will be effective, they will
33
be less likely to attempt the action (Pajares, 2006). In addition, the level of persistence and
mental effort put into achieving a goal is influenced by one’s confidence in their ability to be
successful (Eccles, 2006). A component of motivation includes an individual’s expectations of
success and what value they have on different choices that may be presented (Eccles, 2006).
Self-efficacy beliefs are one’s perceptions of their capabilities and are an essential component of
motivation (Pajares, 2006). Grossman and Salas (2011) describe the importance of the work
environment transfer climate and its influence on motivation
Rueda (2011) explained that there is not one single theory of motivation and noted the
influence that one’s environment and culture may have on motivation. Motivation is not
necessarily the desire to do something, but is often observable to others by actively starting
something in pursuit of some kind of goal (Mayer, 2011). This analysis includes a review of
literature regarding motivational theories and constructs of Emotions and Self-Efficacy Theory.
Emotions: fear and anxiety. MacMullen (2004) explained that “without force of feeling
there is no action; without action, no change” (p.20). While emotions such as excitement and
enthusiasm may have a positive effect on motivation, emotions such as fearfulness have been
shown to have a negative effect on motivation by interfering with activity (Turner, Goodin;
Lockey, 2012).
The significant impact that fear and anxiety may have on nurses confronted by an
aggressive and/or physically violent patient or visitor must be recognized. Holleran (2006)
shared a detailed description of the background of violence specifically in the Emergency
Departments (ED) of hospitals:
It is important to note that unlike most workplaces, the emergency department must
accept anyone who presents himself or herself for care. ED nurses and other staff are
disproportionately exposed to violence, including cases of human abuse and neglect,
34
cases of murder and suicide, aggressive behaviors that are the result of mental illness, and
traumatic events such as motor vehicle collisions (p.523).

Newton, Kelly, Kremser, Jolly and Billet (2009) found that there were common themes
among nurses that correlated with their motivation to practice nursing including a desire to help,
caring, sense of achievement and self-validation. In situations when a nurse is the recipient of
aggression or physical violence, these factors that motivate a nurse to practice nursing are in
jeopardy and could potentially lead to burnout or a nurse leaving the profession entirely. This
avoidance goal may also be an example of mastery avoidance described within Goal Orientation
Theory of achievement motivation by Yough & Anderman (2006). It may also be assumed that a
nurse who is slapped in the face by patient may have a difficult time emotionally caring for that
patient, helping that patient and feeling as though his/her goals were achieved for the patient’s
care that shift. Emotions impact whether one engages in choice, persistence and effort, the
motivational indices discussed above (Rueda, 2011).
If a nurse is fearful or anxious when a visitor or patient becomes aggressive or physically
violent, he/she may choose to try to avoid the situation if possible by tolerating verbal abuse to
avoid escalation of the conflict, try to change his/her patient assignment with another nurse to
avoid the situation or leave the nursing profession completely if the cycle of experiencing fear
and anxiety continues. These strategies may temporarily prevent an escalation in the nurse
feeling more fearful or anxious at that moment, but are not successful strategies if it is believed
that experiencing these behaviors are not “just part of the job” for an RN and should not be
tolerated by the nurse or the organization.
Being anxious and afraid when confronted by an aggressive and/or physically violent
patient or visitor may affect a nurse’s persistence in applying strategies that have been learned
about how to respond in these situations. In addition, if there is a lack of support from the
35
organization such as the absence of policies and procedures that also specifically address
aggression or physical violence by patients or visitors, the nurses’ persistence, choice and effort
may also be influenced. There is a two-way relationship between motivational and knowledge
influences as shown in the Conceptual Framework graphic (Figure A). Even if a nurse learns
methods to de-escalate a situation or how to respond in a situation of physical violence, he/she
may be less likely to persist in using this knowledge if they are fearful or anxious that there are
no supports to help or back them up if his/her interventions are not effective.
Eccles (2006) explains how the perceived cost of persisting and putting effort into
learning and performance can impact motivation. The cost of experiencing anxiety or fear of
being physically or emotionally injured may be perceived to be too great for the nurse and will
influence his or her motivation to persist in their current career. Waschleger, Ruiz-Hernandez,
Llor-Esteban and, Garcia-Ezquierdo (2016) found that nurses who had a higher exposure to
violence resulted in “lower job satisfaction, more emotional exhaustion and more cynicism, and
to a lower level of psychological well-being” (p. 1418).
Daley (2006) described how a person’s behavior may be determined by neutral events,
antecedents and consequences from the environment. An example of a neutral event is a nurse
working in a hospital caring for patients while a stimulus is a patient or visitor who is aggressive
toward a nurse. When this stimulus is added to the neutral event of a nurse caring for patients in
a hospital, the consequence that may occur is a nurse experiencing feelings of fear and anxiety.
Respondent conditioning may then result and interfere with the stakeholder goal because of the
predictable pattern (Daley, 2006). The previously neutral stimulus of caring for patients in the
hospital may ultimately become a conditioned stimulus for fear and anxiety and even though the
real noxious stimulus was the aggressive patient or visitor (Daley 2006). This now conditioned
36
response could understandably have devastating consequences and possibly result in a nurse
choosing not to work in a hospital or leaving the field of nursing altogether.
Self-efficacy. Self-efficacy is a factor in the transfer of training and refers to a person’s
belief in their ability to perform (Grossman & Salas, 2011). While self-esteem refers to a
person’s self-worth in a broader sense, self-efficacy refers specifically to a person’s self-
confidence in his or her ability to perform something (Komarraju, 2014). Pajares (2006)
explained that self-efficacy is an aspect of motivation and unless a person believes that they can
do something, he or she may not put a lot of effort into something or not even attempt to start
something. High self-efficacy can positively influence motivation, while low self-efficacy may
result in little incentive to persist or put effort into a course of action (Pajares, 2006).
Registered Nurses’ self-efficacy. Nurses need to have confidence in their ability to
implement interventions that will have the desired effect of successfully de-escalating or
responding to a patient or visitor who is verbally abusive, threatening or physically violent.
Adriaenssens, DeGucht and Maes (2015) conducted a longitudinal study examining factors such
as job satisfaction, engagement and turnover of nurses who work in emergency rooms. They
found that when nurses had perceived high job control, they had higher levels of engagement at
work and experienced less burnout. If a nurse has high self-efficacy in his or her ability to
intervene successfully in situations when they are confronted by verbal abuse or physical
violence, then they may also perceive themselves to have high job control in these situations. In
contrast, a nurse with low self-efficacy may perceive that he or she has little control in their job
in regards to these situations and not attempt to use an intervention that they have used in the
past or not use it effectively. In general, perceived self-efficacy has also been associated with
more effective strategy use and persistence (Denler, Wolters, & Benzon, 2006).
37
When a nurse experiences fear or anxiety when confronted by a patient or visitor who is
aggressive and/or physically violent, then the nurse’s self-efficacy may be diminished and will
have a negative impact on motivation. Pajares (2006) described the importance of self-efficacy
in one believing that he or she is capable and how this relates back to cognition and
metacognition. If a nurse does not have the appropriate knowledge and skills to intervene when
confronted by a situation of aggression or physical violence, and the situation gets worse or there
are no other supports activated in the hospital, then it is likely that the nurse will feel powerless
and his or her self-efficacy will be low in these situations. The nurse may not be motivated to
learn skills to intervene in the future because he or she believes that they cannot be successful.
However, if, a nurse believes that he or she is capable of learning and applying interventions to
be used when confronted with aggression or physical violence, then he or she is more likely to
also engage in metacognitive learning strategies which may in turn positively influence the
effectiveness of their intervention. Table 3 summarizes the assumed motivation influences and
the assessment of those influences.

Table 3
Assumed Motivation Influences and Assessment
Assumed motivation influences How will it be assessed?

Emotions: Fear and Anxiety:
Nurses may experience fear or anxiety in
their daily work

In a survey, using both fixed and open-
ended questions, ask nurses about how
they feel and cope when a patient or
visitor is aggressive or physically violent
Self -Efficacy:
Nurses need to have confidence in their
ability to implement interventions that will
have the desired effect of successfully de-
escalating or managing a potentially violent
situation

In a survey, ask nurses to indicate their
level of confidence when confronted by a
patient or visitor who is aggressive or
physically violent
38
Organizational Influences
Different organizational factors will be analyzed in regards to the achievement of the
stakeholder goal of Registered Nurses (RNs) being able to describe what to do when confronted
by verbal or physical violence. These assumed organizational factors may be categorized into
cultural model influences and cultural setting influences.
Rueda (2011) described the relationship between cultural models and cultural settings as
one that is dynamic and interactional. Cultural models are shared understandings of how the
world works including what the cultural norms are and what they are not. Cultural models can
help with understanding the invisible aspects of an organization’s culture (Rueda, 2011).
Schneider, Brief and Guzzo (1996) reported that without addressing an organization’s climate or
the “feel” of the organization, then change will not be successful. Cultural settings can be
described by what is observable or the visible aspects of an organizational culture (Rueda, 2011).
In a hospital, examples of the cultural setting may include routine processes such as nurses
reporting vital information about their patients to the next nurse who will be caring for them or
the process of orienting a new staff nurse on an inpatient unit.
RN organizational influences. The literature that will be examined is relevant to the
stakeholder group of Registered Nurses and the stakeholder goal. A description of each assumed
organizational influences with supporting literature is shared.
Cultural model influence 1. The first cultural model influence is the belief that the
problem of violence experienced by the RN is “just part of the job”. If the RN believes that
aggression or physical violence is something that may be expected in his or her role, then they
will not be motivated to report these occurrences or learn what interventions they may use when
these situations occur. Fernandez and Rainey (2006) described that the first step in the process of
39
organizational change is to ensure that there is a need to change. If the experience of aggression
or physical violence is part of the job of the RN, then it is assumed that there may not be a need
to consider this a problem. If an organization’s culture does not communicate the belief that an
RN experiencing verbal abuse or physical violence is not considered “just part of the job” then
the organization will not consider this phenomenon is a problem and will not be motivated to
change. In addition, Krosgaard, Brodt and Whitener (2002) found that trustworthy management
behavior in an organization is greatly dependent on communication and concern. If leaders in an
organization do not share and demonstrate their concern about workplace violence, it may
negatively affect the feeling of trust that employees have within the organization.
Cultural model influence 2. The second cultural model influence is the belief that
physical assaults by patients do not need to be reported unless the RN is so injured that they
require medical attention. Research has demonstrated that physical assaults that occur toward
nurses in healthcare are underreported (Erickson &Williams-Evans, 2000; McKoy & Smith,
2001). The Occupational Health and Safety Administration (OSHA) (2015) explained that
believing that violence is tolerated and that victims will not be able to report incidents to the
police or press charges is in itself an organizational risk factor for workplace violence in
healthcare
Cultural setting influence 1. A cultural setting influence is that there is a lack of training
that RNs receive about how to de-escalate someone who is angry and/or aggressive or how to
respond to someone who becomes physically violent. The priorities of an organization are often
reflected within the things leaders pay attention to, and if training to prevent workplace violence
is not occurring or resources are not being allocated for the training to occur, then it may be
assumed that it is not important in the culture (Schein, 2010).
40
Assault prevention training including how to recognize and respond to hostile behavior
has been shown to be valued by healthcare workers and may result in decreased rates of assault
(U.S. Department of Justice, Federal Bureau of Investigation, 2002; O’Brien, Tariq, Ashraph &
Howe, 2014). Allareddy, et al. (2007) recommended that “hospitals implement a workplace
violence prevention training program that uses consistent and effective methods including
training content, length, modality and accuracy” (p.28). More recently, in December 2015, the
Occupational Safety and Health Administration (OSHA) published a document referred to as a
“road map” for healthcare facilities to use to develop or strengthen a violence prevention
program in their facilities. The five core elements that are described in the violence prevention
program include: management commitment and employee participation, worksite analysis and
hazard identification, hazard prevention and control, safety and health training and
recordkeeping and program evaluation (OSHA, 2015). An organization should not only
implement training and an overall violence prevention program, but evaluate the effectiveness of
that training. OSHA (1998) identified that an organization’s lack of policies and staff training to
recognize and respond to aggressive behavior is a risk factor for workplace violence in
healthcare.
Cultural setting influence 2. A second cultural setting influence is that there is a lack of
a formal process to report incidents of aggression or physical violence and a way to measure and
analyze these incidents. Allereddy, et al. (2007) found that there were gaps between incidents of
violence and reporting. Schein (2010) explained that what leaders pay attention to, measure and
control directly influences an organization’s culture. If there is no formal process to measure
occurrences of violence in a hospital setting, then it may be assumed that this is not important to
41
the organizational culture. Table 4 summarizes the assumed organizational influences and the
assessment of those influences.

Conclusion
Chapter Two outlined the problem of violence experienced by Registered Nurses
(RNs) from patients or visitors and the factors that may influence achievement of the stakeholder
goal of all RNs working in Massachusetts hospitals will articulate at least three interventions
Table 4
Assumed Organizational Influences and Assessment
Assumed organizational influences How will it be assessed?

Cultural Model Influence 1:
There is a belief within organizations that
aggression or physical violence by a
confused or agitated patient is just “part of
the job”

.
In a survey, ask nurses the degree to
which they agree or disagree with
statements about their organization in
regards to aggression or physical
violence by patients or visitors
Cultural Model Influence 2:
There is a belief within organizations that
instances of physical violence by patients do
not need to be reported unless there is an
injury to the nurse requiring care from
Employee Occupational Health Services
(EOHS).

Cultural Setting Influence 1:
There is a lack of required training for
nurses about how to de-escalate someone
who is aggressive or how to respond and to
protect oneself if a patient or visitor
becomes physically violent

Cultural Setting Influence 2:
There is a lack of a formal process to report
incidents of aggression or physical violence
by patients or visitors so they can be
measured and analyzed.

Using both fixed and open-ended
questions, assess the frequency of
reporting, process and experience of
managing a situation in regards to
physical violence by patients or visitors.

In a survey, ask nurses if they have
received training and the content of that
training. The content and medium of
training in regards to managing situations
when a patient or visitor is aggressive or
physically violent.

In a survey, ask nurses if there is a formal
reporting process to report incidents of
aggression or physical violence by
patients or visitors.
42
they may use when confronted by situations of verbal or physical violence. The first section
described the hospital environment, role of the RN in the hospital and the culture of the nursing
profession as it relates to violence. Types of violent behavior that may occur in the hospital were
then described including the potential outcomes for the RN who is the victim of such violence.
The problem of aggression and/or physical violence experienced by RNs in hospitals was then
analyzed through the lens of learning. The assumed influences of knowledge, motivation and the
organization were each analyzed in relation to achievement of the stakeholder goal. Chapter
Three describes a mixed method approach that was used to explore the nature of Massachusetts
RNs’ experiences of aggression and/or violence while working in the hospital. This evaluation
study assessed the influences of knowledge, motivation and the organization on the achievement
of the stakeholder goal.

43
CHAPTER 3: METHODOLOGY
Purpose of Project
The purpose of this project was to complete an exploratory evaluation of nurses’
experiences and beliefs about violence in the workplace. The specific performance issue that
was explored was the violence experienced by Registered Nurses while working in a hospital in
Massachusetts. The methodology and analysis focused on knowledge, motivation and
organizational elements related violence experienced by RNs working in hospitals in
Massachusetts. The stakeholders that were focused on in this analysis were Massachusetts RNs
working in hospitals. While a complete performance evaluation would focus on all stakeholders,
for practical purposes the stakeholder group focused on in this analysis included RNs who are
licensed in Massachusetts who work in hospitals.
Research Questions
The questions that guided this evaluation study addressing the knowledge and skills,
motivation, and organization elements for RNs who are licensed in Massachusetts and work in
hospitals are:
1. What is the nature of the RNs’ experiences in aggression and/or physical violence while
working in the hospital and how are these experiences shaped by knowledge, motivation
and organizational influences?
2. What are the barriers for an organization to measure and evaluate incidents of aggression
or physical violence by patients or visitors towards nurses?
3. What are the recommendations for organizational practice in the areas of knowledge,
motivation, and organizational resources?
44
Gap Analysis Conceptual Framework
The specific analytic approach that was used in assessing the problem of violence
experienced by RNs was a modified gap analysis framework (Clark & Estes, 2008). Clark and
Estes (2008) explained that performance gaps fall into one of three main categories: stakeholder
knowledge, stakeholder motivation or organizational factors (KMO). To improve performance or
implement a solution, there must be a thorough understanding of the factors that influence a
problem. The conceptual framework for this problem began with a gap analysis of knowledge
related influences. Motivation related influences and the impact they have on this problem were
also analyzed, specifically the roles of emotions and self-efficacy. The conceptual framework
then included a gap analysis of the organizational factors in relation to the problem of aggression
and/or physical violence experienced by RNs working in hospitals in Massachusetts.
Knowledge influences literally rest upon the organizational influences within the graphic
presentation of the conceptual model (Figure A). Also demonstrated in Figure A is how the
organizational influences impact motivational influences and could potentially have a positive
effect in decreasing fear and anxiety of nurses in these situations if successfully implemented.
Knowledge, motivation and organizational influences rely on one another and have an influence
on the successful achievement of the stakeholder goal in regards to violence experienced by RNs
working in hospitals.
Participating Stakeholders
The stakeholder population of focus was Registered Nurses (RNs) who work in hospitals
in Massachusetts. The phenomenon or problem of practice was violence experienced by
these Registered Nurses (RNs) working in hospitals in Massachusetts.

45
Survey Sampling Criterion and Rationale
Criterion 1. The individuals surveyed were Registered Nurses (RNs). Although it would
be ideal to have a response rate that is representative of all RNs in the state who work in
hospitals, snowball sampling was used in an attempt to reach a larger sample (see Appendix A
for the content of the survey).
Criterion 2. The RNs surveyed work in hospitals. Because of their responsibility to care
for an assigned patient or group of patients typically for an eight hour or 12 hour shifts, RNs in
hospitals have a significant amount of patient and family contact and may be exposed more than
other healthcare workers to verbal or physical violence. One reason that this investigator chose
not to conduct research in my own organization alone is because of potential perceived power
influences in my role as a Nursing Director supervising many RNs. In addition, Creswell (2008)
explained the importance of avoiding doing research in a location where you have a vested
interest
Criterion 3. The RNs surveyed worked in Massachusetts for the convenience and
interest of the principal investigator. Registered Nurses in Massachusetts accounted for 1,450
work related injuries or illnesses that resulted in days away from work (Massachusetts
Occupational Safety and Health Statistics Program, 2014).
Survey Sampling Recruitment Strategy and Rationale
The Massachusetts Board of Registration in Nursing (2017) reported that there were
115,342 individuals who are RNs in the state of Massachusetts. Over one-third of the
respondents to a Massachusetts RN Workforce Survey reported that he or she worked in a
hospital (Massachusetts Department of Public Health, 2016). Invitations to complete the online
survey were shared with various Massachusetts based nursing organizations, newsletters and
46
individual nurses via social media and email. Snowball sampling was used to obtain a higher
number of responses The credibility of the research findings and generalizability was determined
partially by the number of participants who completed the survey.
Data Collection and Instrumentation
This was a primarily quantitative study with some open-ended items. An embedded
mixed methods approach was used to explore the research questions. The specific instrument that
I used was a survey (refer to Appendix A for the survey instrument). Surveys are very useful to
obtain information about people and complex behaviors and can self-administrated surveys can
be perceived as less threatening, particularly when researching a sensitive topic (Fink, 2013). An
assessment of RNs’ knowledge about responding to situations of physical violence and
aggression in the hospital by patients and/or visitors was included within the survey. Questions
within the survey also identified motivational influences including emotions they experienced
and their self-efficacy in these situations. Also included in the survey were questions used to
assess the organizational influences in regards to an RN’s experience of violence and/or verbal
abuse while working in the hospital including the content of training the RNs may have received
and if it was interactive or one dimensional such as reaching. Using a survey allowed for a
larger sample size, and enabled this investigator to learn some specific information about a lot of
subjects using statistical analysis, as well as the ability to identify any correlations and patterns
between variables. For a qualitative component, the surveys also included 4 open-response
opportunities which allowed for the RNs to respond in a narrative format. RN responses were
examined and themes were identified through the coding process.

47
Survey
An invitation to answer a survey was shared with various nursing organizations,
newsletters and individual RNs in Massachusetts via social media or email. Snowball sampling
was used so that recipients would be able to forward the survey to other nurses if they chose to.
The survey was written in English and administered using the Qualtrics Survey Software
Program (2016) as a platform for the survey. Responses to the survey were anonymous. There
was an opportunity for respondents to enter into a drawing upon completion of the survey for one
of 10 Starbuck’s gift certificates for $10 and the information shared when entering this drawing
was independent from their survey responses for the study.
Included in the survey were 10 fixed response items and 5 items inviting a narrative open
ended response (refer to Table 5). Respondents of the survey did have the option to skip over
questions and not answer them while continuing on to the rest of the survey. Demographic
variables such as the RN’s role in an organization (i.e., caring directly for patients versus a more
administrative role), years of experience working as an RN, gender, age and highest academic
degree obtained were collected in the online survey. Ordinal scales (i.e., range from strongly
disagree to strongly agree), categorical scales (i.e., role in an organization) and continuous scales
(i.e., years of experience as an RN) were used within the survey. Table 5 includes some of the
survey items along with the KMO influences that were assessed through each item.

48
Table 5
Survey Items and KMO Influences Assessed
For the purposes of this study, workplace violence is defined as aggression and/or physical
violence:
Aggression will include verbal communication that is perceived as hostile, angry, threatening or
demeaning and threatening behavior such as the act of punching a wall.

Physical violence will include the actual act of / or attempt to hit, punch, slap, push, kick, spit
upon, scratch, bite, assault with a weapon, sexually assault, squeeze tightly, throw an object
and/or strangle another individual.
Survey Items KMO Influences Assessed
1. On average, how often do you experience acts of aggression or
physical violence towards you by patients or visitors in your
primary workplace?

2. On average, how often do you report incidents of aggression or
physical violence by patients or visitors toward you in your
primary workplace?

3. How would you help a novice nurse manage a situation when a
patient or visitor becomes aggressive or physically violent?

4. How do you personally cope following a situation when a
patient or visitor was aggressive or physically violent?

5. How effective do you believe that your primary workplace’s
approach to addressing issues of aggression and physical
violence from patients or visitors in the workplace?

6. My organization takes incidents of aggression or physical
violence by patients or visitors seriously
Range from 1 (strongly disagree) to 4 (strongly agree)

7. I am confident in my ability to de-escalate an aggressive
patient or visitor
Range from 1 (strongly disagree) to 10 (strongly agree)

8. I am confident in my ability to protect myself if a patient or
visitor becomes physically violent towards me
Range from 1 (strongly disagree) to 10 (strongly agree)

9. My supervisor takes appropriate action when a patient or
visitor is aggressive or physically violent towards me
Range from 1 (strongly disagree) to 4 (strongly agree)

O1

K1, K2
O-CM2, CS2

K1, K2
M2

K3, K4
M1

O1, O2, O3

O1, O2, O4

K2, K3, K4
M2

K2, K3, K4
M2

O1, O2, O3
49
Table 5 (continued)
Survey Items and KMO Influences Assessed
Survey Items KMO Influences Assessed
10. When a patients or visitor becomes aggressive or physically
violent towards me I feel:(open ended)

11. My work area has a “panic button” or some type of way to
silently alert security about a safety threat in my area
a. Yes b. No c. I don’t know

12. My organization has a formal Hospital Safety Report or
Incident Reporting process to report when patients or visitors
are aggressive or physically violent
b. Yes b. No c. I don’t know

13. I am encouraged to complete Hospital Safety Reports/or some
type of Incident Report whenever a patient is aggressive or
physically violent toward me
Range from 1 (strongly disagree) to 4 (strongly agree)

14. I have been trained by my organization about the following
topics:
(select all that apply)
c. De-escalation techniques
d. Responding to a verbal threat
e. Strategies to protect myself from physical violence
f. When to call Security/ Public Safety
g. How to report when a patient is physically violent
toward you
h. Other: _______________
i. Not Applicable

15. Do you have any other thoughts that you would like to share
about the issue of aggression and physical violence in
hospitals? (open-ended)
Key
K4
M1

K1
O3

K1, K2
O2, O4

O1, O2, O4

K1, K2
O3

K
M
O
K1: Knowledge Influence- Conceptual
K2: Knowledge Influence- Procedural
K3: Knowledge Influence – Metacognitive 1
K4: Knowledge Influence- Metacognitive 2
M1: Motivational Influence– Emotion
M2: Motivational Influence- Self Efficacy
O1: Organizational Influence- Cultural Model 1
O2: Organizational Influence- Cultural Model 2
O3: Organizational Influence- Cultural Setting 1
O4: Organizational Influence- Cultural Setting 2
(As outlined in Table 2, Table 3 and Table 4)

50
Assessment of knowledge influences. Conceptual knowledge was assessed by asking
RNs how often they report incidents of aggression or physical violence, mechanisms that may
exist in their work area to alert security about a safety threat and the content of training that they
may have received (i.e., responding to a verbal threat, when to call security, etc.). In addition,
RNs were asked, “How would you help a novice nurse manage a situation when a patient or
visitor becomes aggressive or physically violent?” to assess the conceptual knowledge of
knowing what supports are available to them if a patient or visitor becomes aggressive or
physically violent.
Procedural knowledge of nurses was assessed in regards to their ability to implement
strategies that may de-escalate a situation and/or to respond when a patient or visitor becomes
aggressive or physically violent in the hospital by asking nurses how they would help a novice
nurse manage this type of situation and by asking nurses to self-report their level of confidence
in regards to their ability to de-escalate an aggressive patient or visitor as well as their ability to
protect themselves if a patient or visitor became physically violent.
To assess RNs’ metacognitive knowledge about reflecting upon their own practice both
in de-escalating situations and how effective their interventions were when responding to
aggression or physical violence, they were asked about how they would help a novice nurse in
this type of situation. RNs were also asked, “How do you personally cope following a situation
when a patient or visitor was aggressive or physically violent?”. In addition, RNs’
metacognitive knowledge of having self-awareness about how emotions that they may
experience may influence their own behavior when confronted by situations of aggression or
physical violence was assessed by asking them to describe how they feel when a patient or
visitor becomes aggressive or physically violent.
51
Assessment of motivational influences. The RNs’ motivational influences were
assessed specifically in regards to their emotions and self-efficacy within the survey. The two
items in the survey intended to assess the motivational influence of emotion were, “When a
patient or visitor becomes aggressive or physically violent towards me I feel: (open ended)” and
“How do you personally cope following a situation when a patient or visitor was aggressive or
physically violent?”. To assess the self-efficacy of RNs in their ability to implement
interventions that will have the desired effect of successfully de-escalating or managing a
potentially violent situation, they were asked to self-report their confidence level of each
choosing a number from 1 (being the lowest) to 10 (being the highest).
Assessment of organizational influences. Organizational influences were assessed
including the cultural model influence of the belief that may exist within organizations that
aggression or physical violence by a confused or agitated patient is “just part of the job” by
asking RNs questions about the degree to which their organization takes incidents of aggression
or physical violence by patients or visitors seriously and also by asking RNs how often they
themselves report these incidents when they do occur. In addition, the narrative responses to
question about how they would help a novice nurse manage this type of situation may also assess
this cultural model influence.
Another cultural model influence that was assessed was the belief within organizations
that instances of physical violence by patients do not need to be reported unless there is an injury
to the nurse requiring care from Employee Occupational Health Services (EOHS). RNs were
asked how often they report these types of incidents when they do occur and they were also
asked if they are encouraged to complete some type of incident report whenever a patient is
aggressive or physically violent toward them.
52
A cultural setting organizational influence that there may be a lack of required training
for nurses about how to de-escalate someone who is aggressive or how to respond and to protect
oneself if a patient or visitor becomes physically violent was assessed by asking RNs about
training they may have received in the past and how they would help a novice nurse in this type
of situation. In addition, RNs were asked, “How effective do you believe that your primary
workplace’s approach to addressing issues of aggression and physical violence from patients or
visitors in the workplace?” (open ended response).
The cultural setting influence of a lack of a formal process to report incidents of
aggression or physical violence by patients or visitors was assessed by asking the RNs if their
hospital had reporting system, if they were encouraged to report these incidents in this reporting
system and how effective they believe their workplace’s approach was in addressing these types
of issues. The last question in the survey, “Do you have any other thoughts that you would like
to share about the issue of aggression and physical violence in hospitals?” was included to
optimize the ability to capture KMO influences that may not have been included in other
responses. Table 5 illustrates survey items with the corresponding KMO influence(s) assessed
by each item. Refer to Appendix A for an entire list of survey items including demographic
questions.
Data Analysis
Since both quantitative and qualitative research methods were applied in this study, the
analysis will be both exploratory and descriptive. To analyze the open-ended responses within
the survey this investigator coded the data and developed a codebook reflecting the conceptual
framework in relation to answering the research questions. Descriptive statistics was applied to
for the quantitative analysis.
53
Validity and Reliability
Because the survey instrument was designed by this investigator, but patterned after
existing instruments, reliability and validity was not pre-established. Morgan, Gliner and
Harmon (1999) explained that there is a difference between research validity and measurement
validity. Research validity refers to the study being worthwhile to do whereas measurement
validity describes the quality of the instrument to collect data (Morgan, Gliner and Harmon,
1999). A thorough literature review about this research topic demonstrated the validity of
conducting the study. Violence toward healthcare workers is a problem and that many
healthcare workers have reported experiencing an assault during the past year while at work but
most of these assaults are not reported to hospital administrators (Erikson & Williams-Evans,
2000; Hodgson, Reed, Murphy, Lehmann & Warren, 2004; Kvas & Sejack, 2014).
Content validity helps ensure that the method of data collection helps answer the research
question, or may determine how well the test or instrument measures what it is supposed to be
measure in quantitative research (Mayo, 2015; Robinson-Kurpius & Stafford, 2006). Reliability
of an instrument refers to the accuracy and dependability of an instrument used in a research
study (Mayo, 2015). Creswell (2008) explained that validity in quantitative research is “whether
one can draw meaningful and useful inferences from scores on the instruments” (p.160).
Robinson-Kurpius and Stafford (2006) explained that the length of an instrument such as
a survey can affect its reliability. The survey instrument contained a sufficient number of items
to answer the research questions to improve reliability but the survey was not too long which
would have potentially decreased the completion rate. True reliability assumes that there is one
single reality when in fact, there are many different variables that will influence the data
collected (Merriam & Tisdell, 2009). For example, the participants in this research study
54
practiced in different hospitals and in different specialty areas within the state of Massachusetts.
The reliability may be affected if this study was replicated in another state or using a different
sampling methodology.
To further maximize reliability, this investigator tested the survey with individuals who
have similar professional backgrounds as my planned sample for feedback and peer review. A
factor that was considered is the possibility for non-response bias. It may be possible that for
various reasons, subjects may have chosen not to complete the survey and this may have resulted
in data that was skewed one way or another (Nicholson, 2014). However, by having a large
sample size for the survey, it was hoped that this mitigated the non-response bias (Fink, 2013).
Mayo (2015) explained how an instrument may be reliable, but not valid for a specific research
study so it was important that both validity and reliability be examined.
Participants were not able to “go back” to change an answer to a question within the
survey to avoid the possibility that a future question may influence their answer to a previous
one, however this may have led to some questions not being answered. If a participant did not
answer greater than 50% of the items, their data was not included in the analysis.
Credibility and Trustworthiness
Credibility in research may be defined as being believed or trusted and asking if the
research findings reflect reality (Creswell, 2008; Wagar, 2014). Credibility and trustworthiness
are closely aligned. Fink (2013) explained that the credibility of research findings, particularly
with surveys may depend upon the size of a sample. If the sample size or response rate is too
low, questions about the study’s credibility will arise. Because the data collection instrument was
both quantitative and qualitative, there was an opportunity to discover new or unexpected
information. Cope (2014) also recommended ways to enhance credibility and trustworthiness
55
explained that “by providing a description of the strategies and rich, vivid quotes from the
participants, the reader can personally critique the credibility of the study and substantiate the
interpretations” (p.90).
I also acknowledged who I am and what I brought to the research study. For example, I
am a nurse and have personally experienced aggression and physical violence from patients and
visitors while working in the hospital. I believe personally that this is a problem. During this
study, I was aware of the potential for my feelings or beliefs to affect how I interpreted the data
and used strategies to ensure objectivity including seeking support from my Dissertation Chair as
needed.
Ethical Considerations
A researcher should consider ethical issues at each step in the process (Glense, 2011);
Maxwell, 2013). There are many factors to consider when ensuring that ethical choices are made
while conducting research. This investigator chose not to conduct this research study within my
organization alone. Creswell (2008) stated that it is important to acknowledge potential power
imbalances in a research study. I was in a supervisory role in a hospital and considered my role
in directly supervising many RNs and if my perceived position of power could potentially
influence the responses to my survey. By surveying RNs in hospitals in Massachusetts, I
eliminated the perception of nurses feeling pressured or coerced into participating in the study.
Ethically, I had the responsibility to provide informed consent of the participants
(Creswell, 2008). There are also federal, state and institutional mandates that must be followed
when conducting research to protect human subjects and that includes obtaining informed
consent (University of Southern California, 2016; U.S. Department of Health and Human
Services, 2016). The informed consent included my name and licensure as an RN for full
56
disclosure and that I am currently a student at the University of Southern California. The
purpose of the study was shared which was to evaluate the knowledge, motivation and
organizational influences in regards to aggression and physical violence toward RNs in
Massachusetts hospitals and the degree to which Massachusetts Hospitals successfully
implementing violence prevention programs. The purpose of the study was included in the
Information Sheet (refer to Appendix B). The study procedures were described such as
completing a confidential online questionnaire which was estimated to take 15 to 30 minutes to
complete. The potential risks and discomforts that were anticipated were minimal as there was a
small risk that some of the questions may conjure unpleasant feelings or memories. Refer to
Appendix B for the details included in the Information Sheet.
The Information Sheet stated that there were no direct benefits from participating in the
study including payment, however the anticipated benefit was to learn more about the
knowledge, motivation and organizational influences in regards to aggression and physical
violence toward RNs in Massachusetts hospitals and the degree to which Massachusetts
Hospitals were successfully implementing violence prevention programs. Participants were
informed that their information would be kept confidential as far as permitted by law, that their
participation was voluntary and that they may withdraw from the study at any time. Responses to
the online survey were anonymous and stored in a password protected repository.
Alternatives to participating in the study were shared and the alternative was to not
participate in the study. The participants’ rights, the contact information for the investigator,
Dissertation Chair and the USC Institutional Review Board were also shared in the Information
Sheet. Because this was a survey, involving adults, there was not a need for a signed consent.

57
CHAPTER 4: RESULTS AND FINDINGS
Overview
The purpose of this project was to complete an exploratory evaluation of nurses’
experiences and beliefs about violence in the workplace. The specific performance issue that
was explored was the violence experienced by Registered Nurses while working in a hospital in
Massachusetts. The questions that guided this evaluation study addressing the knowledge and
skills, motivation, and organization elements for RNs who are licensed in Massachusetts and
work in hospitals were:
1. What is the nature of the RNs’ experiences in aggression and/or physical violence while
working in the hospital and how are these experiences shaped by knowledge, motivation
and organizational influences?
2. What are the barriers for an organization to measure and evaluate incidents of aggression
or physical violence by patients or visitors towards nurses?
3. What are the recommendations for organizational practice in the areas of knowledge,
motivation, and organizational resources?
Participating Stakeholders
The stakeholders of focus were RNs who work in hospitals in Massachusetts. The
phenomenon or problem of practice evaluated was violence experienced by RNs working in
hospitals in Massachusetts. Snowball sampling was used to obtain a sample population and an
exact number of survey links that were sent cannot be determined since recipients could have
forwarded the survey link to other RNs. At a minimum, electronic invitations and link to
complete the survey were sent to: 214 individual RNs and requests to post the invitation and
58
survey were sent to twelve Facebook nursing organization membership pages. However it was
not possible to know if the organizations posted the survey or not as membership is often private.
Recipients were asked to forward the survey to other RNs in Massachusetts to achieve a larger
sample via snowball sampling. 311 individuals attempted to take the survey in Qualtrics (2016)
while 254 met the criteria for the study population of working as a Registered Nurse in a hospital
in Massachusetts.
Demographics. Of the 254 respondents, 7.1% were male and 92.1% were female. 0.4%
of respondents reported being Mexican, Mexican American or Chicano while 3.2% reported
being another Hispanic, Latino or Spanish origin. 96% of the respondents identified as white,
1.2% of the respondents identified as black or African American, 0.80% identified as Filipino,
0.80% identified as Other Asian, 0.80% identified as Some Other Race, 0.40% identified as
American Indian or Alaska Native and 0.40% identified as Asian Indian (see Figure B). The
highest percentage of respondents (38.8%) worked in Boston, 21.6% worked in Central
Massachusetts, 16% worked in the Greater Boston Area, 8% reported working in another region
such as the Cape and Islands and Southeastern Massachusetts, 6% worked on the South Shore,
4.8% worked on the North Shore and 4.8% worked in Western Massachusetts (see Figure C).
65.4% of the respondents reported having at least a Bachelor’s degree in Nursing while 27.2%
reported having a Master’s degree in Nursing (see Figure D).

59

Figure B. Sample RNs’ Race

Figure C. Location of hospitals where RNs in sample work

Mexican, Mexican
American, Chicano,
0.4%
Another Hispanic,
Latino or Spanish
Origin, 3.2%
White, 96.0%
Black or African
American, 1.2%
American Indian or
Alaska Native,
0.4%
Filipino, 0.8%
Other Asian, 0.8%
Some other race,
0.8%
Race and Ethnicity
Boston, 38.8%
Central
Massachusetts,
21.6%
Greater Boston,
16.0%
Other (ie, Cape and
the Islands,
Southeastern
Massachusetts,
etc.), 8.0%
South Shore, 6.0%
North Shore, 4.8%
Western
Massachusetts,
4.8%
Hospital Locations
60

Figure D. Sample RNs’ educational preparation
RNs who completed the survey ranged in years of experience from one to 40 years with a
median of 18.8 years of experience and a mode of 30 years (Figure E). The age range of RNs
who completed the survey was from 22 to 70 years of age, with a mean of 44.39 years of age
with a standard deviation of 12.04 (Figure F). 58.9% of the respondents were RNs who provided
direct patient care, 23.3% reported being in a supervisory or administrative role, 13.4% reported
being in another nursing leadership role while 3.2% reported being in another role such as a
Nurse Practitioner or Case Manager (Figure G, Table 7).
0% 10% 20% 30% 40% 50% 60% 70%
Diploma in Nursing
Associate's in Nursing
Associate's other
Bachelor's in Nursing
Bachelor's other
Master's in Nursing
Master's other
PhD or DNP
Doctorate other
Other
# of RNs
Education
(RNs may have more than one degree)
61

Figure E. Sample RNs’ years of experience

Figure F. Ages of RNs in Sample
4 or less 5 to 9 10 to 14 15 to 19 20 to 24 25 to 29 30 or
longer
0%
5%
10%
15%
20%
25%
30%
Years
Percent of sample
RNs' Years of Experience
0% 5% 10% 15% 20%
22 to 25
26 to 30
31 to 35
36 to 40
41 to 45
46 to 50
51 to 55
56 to 60
61 to 65
66 to 70
Percent of sample
Years
Ages of RNs
62

Figure G. RN respondents’ primary role in organizations
Results and Findings
Scope of the problem. As shown in Table 6 and Figure H, 12% of RNs reported that
they never experience aggression or physical violence from patients or visitors. While 33.2% of
RNs reported that on average, they experienced aggression or physical violence from patients or
visitors a couple of times a year, 11.2% of RNs reported that on average they experience this
once every 3 months, 17.2% of RNs reported that on average they experience this once a month,
14% of RNs reported that on average they experience aggression or physical violence by patients
or visitors once a week and 7.6% of RNs reported that on average, they experienced aggression
or physical violence daily by patients or visitors. Figure H is a visual representation of the
reported frequency of aggression or physical violence experienced by RNs from patients or
visitors.

Direct patient
care provider
Supervisory or
administrative
role
RN in another
nursing
leadership role
Other
0%
10%
20%
30%
40%
50%
60%
70%
What is your primary role in your organization?
63

Figure H. RNs’ reported frequency of experiencing acts of aggression or physical violence by
patients or visitors.
Assessment of Knowledge Influences
When asked how often they experience acts of aggression or physical violence by
patients or visitors, 12% of the RNs reported never, 33.2% reported experiencing this a couple of
times a year, 11.2% reported once every three months, 17.2% reported once a month, 14%
reported once a week, 7.6% reported every day and 4.8% reported other. Table 6 summarizes
the RN responses to questions about frequency of experiencing aggression or physical violence
and frequency of reporting such incidents. Figure I is a visual representation of the frequency of
reporting incidents of aggression or physical violence by RNs.

Never
A couple of times
a year
Once every 3
months
Once a month
Once a week
Everyday
Other
0% 5% 10% 15% 20% 25% 30% 35%
On average, how often do you experience acts of aggression or physical violence towards
you by patients or visitors in your primary workplace?
64
Table 6
RN Survey Results of Frequency of Experiencing and Reporting Aggression or Physical Violence
by Patients or Visitors
Statement Response n %
On average, how often do you experience acts
of aggression or physical violence towards
you by patients or visitors in your primary
workplace?
Never
A couple of times a year
Once every 3 months
Once a month
Once a week
Everyday
Other
30
83
28
43
35
19
12
12
33.2
11.2
17.2
14
7.6
4.8

On average, how often do you report
incidents of aggression or physical violence
by patients or visitors toward you in your
primary workplace?

Never
Rarely
Some of the time
Most of the time
Always

54
81
64
26
23

21.8
32.7
25.8
10.5
9.3

Figure I. RNs’ frequency of reporting incidents of aggression or physical violence by patients or
visitors
In narrative responses, one of the tools identified by RNs was using a “panic button” or
other similar silent alert system to notify Security or Public Safety of a threat. From the survey
Never
Rarely
Some of the time
Most of the time
Always
0% 5% 10% 15% 20% 25% 30% 35%
How often do you report incidents of aggression or
physical violence?
65
responses, 59.2% of the RNs indicated that their work area has a “panic button” or some other
type of system to silently alert Security or Public Safety of a threat in his or her area. However,
6% of respondents did not know if his or her work area had this type of alert system (as shown in
Figure J). Eighty-seven percent of the RNs reported that their organization had a formal
reporting process that can be used if a patient or visitor is aggressive or physically violent as
shown in Figure K.

Figure J. Presence of a way to silently alert security about a safety threat

Figure K. RNs’ knowledge of existence of a formal process to report aggression or physical
violence by visitors
0%
20%
40%
60%
80%
No Yes I don't know
My work area has a "panic button" or some type of way to
silently alert security about a safety threat in my area
0%
20%
40%
60%
80%
100%
No Yes I don't know
My organization has a formal Hospital Safety Report or
Incident Reporting process to report when visitors are
aggressive or physically violent
66
In the open-ended responses to the question about how would they help a novice nurse
manage a situation when a patient or visitor became aggressive or physically violent, RNs
identified additional supports that were available in these situations along with other strategies.
One nurse included advice to prevent or mitigate risk and stated, “…be careful when you push
them to do things that they DO NOT want to do…assess your risk with ALL patients. Nurses
are present as ‘intimate strangers’ and in a posture of serving- remind patients of the nurse’s
role…”. One-hundred and forty-seven RNs included in their responses to “call for help” in these
situations while 94 respondents specifically advised calling Security or Public Safety as a
response.
Seventy-three RNs explained that it was important to keep a safe distance from the
patient or visitor and/or to remove oneself from the situation. The suggestion of using de-
escalation techniques was included in 62 of the responses. Reporting the situation to a Charge
Nurse or Nursing Supervisor was included in 45 of the RNs’ responses. Thirty-one RNs
specifically described how they as would intervene and help the novice nurse in these situations.
Twenty-five respondents advised to remain calm and/or to speak in a calm voice and one RN
advised to, “remain calm…don’t approach a bedside from the bottom (legs are stronger than
arms) try to get to the head of the bed”. Twenty-two respondents recommended that novice
nurses attend a type of crisis management training.
The activation of some type of emergency response that is specific to this type of
situation of aggression or physical violence was included in 19 of the responses. The importance
of making sure that there were no barriers between the nurse and the exit of the room was
advised in 19 responses as one RN explained to:
67
never allow a patient or visitor to get between you and the exit. If there is a situation
where you feel you can be put in physical danger you have to remember to care for
yourself and not put yourself in harm’s way, that is not your job

Within RNs’ responses to this question about helping a novice nurse manage this type of
situation, 17 included that aggression or physical violence should not be tolerated. Only four
responses included reporting the situation in a formal type of report. See Figure L for a visual
representation of the most common themes identified from the RNs’ responses.

Figure L. Major Themes from Narrative Responses to Question about Helping a Novice Nurse
Manage a Situation when a Patient or Visitor became aggressive and/or physically violent

0 20 40 60 80 100 120 140 160
Call for Help/ Get Help
Calling Security/ Public Safety as an Option
Keep Safe Distance/ Remove Self from Situation
Use De-escalation Techniques
Report to Charge Nurse or Supervisor
Respondent would Intervene/ Help the Novice
Remain Calm/ Speak in Calm Voice
Attend Training (such as Crisis Management…
Emergency Response Activation/ Code Response
Ensure No Barriers Between You and the Exit
Aggression / Physical Violence should Not be…
Debrief
Report to MD
Never be Alone in a Room in that Situation
Medicate as ordered by MD (if patient)
Complete a Formal Report
Use of Physical Restraints as ordered by MD (if…
# of Narrative Responses
How would you help a novice nurse manage a situation when a patient
or visitor became aggressive and/or physically violent?
68
Assessment of Motivational Influences
Emotion. When asked how RNs feel when a patient or visitor becomes aggressive or
physically violent towards them, sixty-five RNs’ responses included the theme of feeling scared,
afraid and/or fearful. Thirty respondents reported feeling angry when these events occur as one
RN described feeling “annoyed; an aggressive patient takes up time that I could be devoting to a
patient who is sick or injured”.
Twenty-eight RNs reported feeling worried, stressed, anxious and/or nervous. Twenty-
five of the RNs’ responses included self-attributed feelings of stupid, embarrassed, belittled,
guilty, it’s my fault, sad, less, defeated, inferior and/or hurt. One RN reported feeling, “insulted,
that I don’t matter, disrespected, inferior. Like a punching bag” while another RN explained
feeling “like whatever I do is wrong because management will not support staff”.
Twenty-three respondents described feeling confident when these incidents occurred
while 23 RNs’ responses indicate that they feel as though they want to leave the nursing
profession. Eighteen RNs included in their responses feeling supported and/or that they have
resources they can call. Twenty RNs’ responses indicated that these events are part of their job
as one stated feeling “that it’s part of the job and leave my feelings at work when I leave”.
Twenty RNs’ responses included descriptions of feeling threatened and/or intimidated.
The theme of frustration was included in 16 of the RNs’ responses while empathy was expressed
in 13 of the responses. The feeling of being upset was shared in 13 of the responses, feeling
vulnerable was included in 11 of the responses and feeling unsafe was included in 10 of the
responses. See Figure M for a visual representation of the most commonly identified themes
from the RNs’ responses.
69

Figure M. Major Themes from Narrative Responses to Question about Emotions

Coping. When asked how they personally cope following a situation when a patient or
visitor was aggressive or physically violent, 31 of the RNs included in their response that they
consider these situations to be “part of the job”, they “don’t take it personally” and/or they
“move-on and/or get back to work”. One RN stated that when these situations occur,
“emotionally- the scare of the incident leaves me shaken” while another reported:
I actually had a patient kick me in the chest, breaking three ribs, this resulted in a week
long hospitalization. I will admit that afterwards I had some definite resistance to dealing
with another patient that was beginning to escalate. Sixty-four of the RNs’ responses
0 10 20 30 40 50 60 70
Scared, afraid, fearful
Angry
Worried, stressed, anxious, nervous
Stupid, embarrassed, belittled, guilty, it's my…
Confident
Want to leave nursing profession
It's part of the job
Threatened, intimidated
Supported, have resources to call
Frustrated
Empathetic
Upset
Vulnerable
Unsafe
Violated
# of Narrative Responses
When a patient or visitor becomes aggressive or physically violent
towards me, I feel….
70
included the themes such as talking, discussing, venting and/or getting support from other
nurses or colleagues.

Talking, informing, notifying and/or getting support from nursing leadership was
included in 25 of the responses. Another way that explained how they coped included debriefing
with others which was contained in 25 of the narrative responses. Twenty-three respondents
included notifying Security, Public Safety and/or activating some type of emergency response
system. Personal reflection was included in 21 of the responses about coping. Twelve RNs
described therapeutic coping strategies such as exercise, religion, humor, medication and/or
therapy and 10 RNs described that seeking support from family or friends was a way to
personally cope.
Nineteen responses included negative coping strategies which included such things as
shutting down, drinking, having no time to cope or disruption of sleep as one RN described, “I
shut down. I do not provide the care I’m required to do and do not go above or beyond”.
Fifteen of the respondents included statements about empathizing with the patient or
visitor, rationalizing that the behavior is from either a medical or psychiatric condition and/or
that the person is under a lot of stress as one RN explained, “…I feel nursing staff can handle a
demented patient who is squeezing or scratching..”. Eight of the RNs’ responses included
completing a formal report of the event as part of coping however one RN reported that “many
times I have kept situations like this to myself; I don’t talk about them a lot”. Figure Nis a visual
representation of the most common themes identified from the RNs’ responses.
71

Figure N. Major Themes from Narrative Responses to Question about Coping

Self-Efficacy. Table 7 contains descriptive statistics of the results of RNs’ self-reports of
confidence in his or her ability to de-escalate an aggressive patient or visitor and to protect
himself or herself if a patient or visitor became physically violent. On a scale of 0 to 10, zero
being not at all confident and ten being very confident, the mean response was 6.64 in RNs’ self-
reports of confidence in his or her ability to de-escalate an aggressive patient or visitor. One
nurse scored himself or herself as a 0 while two other nurses scored themselves as a 1. On a scale
of 0 to 10, the mean response was 5.93 in RNs’ self-report of confidence in his or her ability to
0 10 20 30 40 50 60 70
Talking, discussing, venting, getting support from
other nurses/ colleagues
Part of the job/ don't take it personally/ move-on/
get back to work
Talking, informing, notifying, getting support from
nursing leadership
Debriefing with others
Notify Security/ Public Safety or activate a security
system
Personal reflection
Negative coping strategies
Empathize/ rationalize that the behavior is from
either a medical/ psychiatric condition or that the…
Support from family/ friends
Therapeutic coping strategies
Incident / Formal Reporting
Notify Police (outside hospital)
# of Narrative Responses
How do you personally cope following a situation when a patient or
visitor was aggressive or physically violent?
72
protect himself or herself if a patient or visitor became physically violent. However, the Standard
Deviations of 1.98 and 2.42 indicate that there was a wide variability of responses. Six nurses
scored themselves as a 0 while another six scored themselves as a 1. Figure O is a visual
representation of the mean self-reported confidence scores of the RNs.
Table 7
RNs’ Reports of Self-Efficacy in Regards to Ability to De-escalate or Protect Oneself-
0 (being not at all confident) to 10 (being very confident)
Statement n M Median Mode SD Variance Minimum Maximum

Ability to de-escalate
an aggressive patient
or visitor

226

6.64

7

8

1.98

3.90

0

10
Ability to protect
oneself if a patient or
visitor becomes
physically violent
towards you
222 5.93 6 8 2.42 5.87 0 10

73
Figure O. RNs’ Reports of Self-Efficacy in Regards to Ability to De-escalate or Protect Oneself-
0 (being not at all confident) to 10 (being very confident)
Assessment of Organizational Influences
The majority of the RNs (77%) reported having received training by their organization
about when to call Security or Public Safety for assistance as shown in Figure P. In addition, the
RNs reported that they were trained about de-escalation techniques (60%), how to report when a
patient is physically violent (59%), strategies to protect oneself from physical violence (51%)
and how to respond to a verbal threat (46%).
0
1
2
3
4
5
6
7
8
9
10
Confidence in your ability to
de-escalate an aggressive
patient or visitor
Confidence in your ability to
protect yourself if a patient or
visitor becomes physically
violent towards you
Confidence level of RNs
Scale from 0 ( being not at all confident )to 10 (being very confident)
74

Figure P. The percentage of RNs who reported having received training in each topic
Eighty-seven percent of the RNs reported that their organization did have a formal
hospital safety report or incident reporting process to report when a patient or visitor is
aggressive or physically violent (Figure K). In response to the statement, “my organization takes
incidents of aggression or physical violence seriously”, 32.8% of the RNs strongly agreed,
21.7% agreed, 24.9% somewhat agreed, 10.6% somewhat disagreed, 7.7% disagreed and 2.6%
strongly disagreed (Table 8 and Figure Q).
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
De-escalation
techniques
Responding to
a verbal threat
Strategies to
protect myself
from physical
violence
When to call
security/
public safety
How to report
when a patient
is physically
violent
towards me
Other Not
Applicable
I have been trained by my organization about the following topics:
75

Figure Q. RNs’ level of agreement with the statement, my organization takes incidents of
aggression or physical violence by patients or visitors seriously.
In response to the statement “my supervisor takes appropriate action when a patient or
visitor is physically violent towards me”, 21.1% of RNs strongly disagreed, 7.7% disagreed,
10.2% somewhat disagreed, 23% somewhat agreed, 32.3% agreed, and 24.7% of the respondents
strongly agreed (Table 8 and Figure R). In response to the statement, “I am encouraged to
complete hospital safety reports whenever a patient or visitor is aggressive and/or physically
violent towards me”, 38.8% of RNs reported that he or she strongly agreed, 22.8% agreed,
17.2% somewhat agreed, 9.5% somewhat disagreed, 7.3% disagreed, and 4.3% strongly
disagreed (Table 8 and Figure S).
0%
5%
10%
15%
20%
25%
30%
35%
Strongly
disagree
Disagree Somewhat
disagree
Somewhat
agree
Agree Strongly agree
My Organization Takes Incidents of Aggression or Physical Violence
by Patients or Visitors Seriously
76

Figure R. RNs’ level of agreement with the statement, “my supervisor takes appropriate action
when a patient or visitor is physically violent towards me”
Table 8
RN’s Level of Agreement with Statements
Statement Response n %
My organization takes incidents of aggression
or physical violence by patients or visitors
seriously
Strongly disagree
Disagree
Somewhat disagree
Somewhat agree
Agree
Strongly agree

6
18
25
58
51
77
2.6
7.7
10.7
24.7
21.7
32.8
My supervisor takes appropriate action when
a patient or visitor is physically violent
towards me
Strongly disagree
Disagree
Somewhat disagree
Somewhat agree
Agree
Strongly agree

5
18
24
54
76
58
21.1
7.7
10.2
23
32.3
24.7
I am encouraged to complete hospital safety
reports/ or some type of incident report
whenever a patient is aggressive or physically
violent towards me
Strongly disagree
Disagree
Somewhat disagree
Somewhat agree
Agree
Strongly agree
10
17
22
40
53
90
4.3
7.3
9.5
17.2
22.9
38.8

0%
5%
10%
15%
20%
25%
30%
35%
Strongly
disagree
Disagree Somewhat
disagree
Somewhat
agree
Agree Strongly
agree
My Supervisor Takes Appropriate Action when a Patient or Visitor is Physically
Violent towards Me (%)
77

Figure S. RNs’ level of agreement with the statement “I am encouraged to complete hospital
safety reports/ or some type of incident report whenever a patient is aggressive or physically
violent towards me”
In response to the open-ended question about how effective their workplace’s approach is
to addressing issues of aggression and physical violence from patients or visitors, seventy-four of
the RNs expressed believing that their primary workplace’s approach was effective (see Figure
T). One RN shared, “I feel like there will always be aggressive patients and visitors that we will
have to deal with in this occupation” and another reported that, “…I work in the emergency
room, my aggressive patients are either under arrest, drunk, on drugs (or) psych patients”.
Twenty-one of the RN respondents described that training is offered at their hospital while
another twenty-one reported that Security or Public Safety is responsive and supportive.
Twenty-six RNs’ responses included the belief that incidents are not taken seriously
and/or nothing is done by the hospital as one RN explained:
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
Strongly
disagree
Disagree Somewhat
disagree
Somewhat
agree
Agree Strongly
agree
I am Encouraged to Complete Hospital Safety Reports/ or Some Type
of Incident Report whenever a Patient is Aggressive or Physically
Violent towards Me
78
I was recently punched by an 85 yr old male who was attempting to throw himself down
a flight of stairs. The response I received when calling the night intern for chemical
restraints (after 4 pts. failed) was a laugh that I had (been) assaulted. Physicians
unfortunately do not fully grasp the amount of aggression and physical abuse that nurses
endure daily, many without saying a word.

Forty-four of the RNs’ expressed that their primary workplace’s approach needed
improvement as one RN explained, “they (administration) boast a no tolerance policy, but they
don’t support the assaulted employee in anything important, such as legal advice or just holding
your hand in court”. Forty-two of the RN responses described that they believe that their
primary workplace’s approach is ineffective, as one RN explained,
patient to nurse or visitor to nurse aggression and violence doesn’t seem to be addressed
much. We have safety huddles with staff and management during change of shift. We go
through the room numbers and say who may be a fall/ safety risk. If it is known that a
patient likes to hit, spit, etc. it is mentioned in a nonchalant way.

Figure T. Major Themes from Narrative Responses to the Question about Effectiveness of
Approach from Workplace in Addressing Issues of Aggression and/or Physical Violence
74
44
42
26
21
21
14
8
6
0 10 20 30 40 50 60 70 80
Effective
Needs Improvement
Not Effective
Incidents are not taken seriously and/or nothing…
Training is offerred at his/her hospital
Security/ Public Safety is responsive or supportive
Hospitals believe that patients and families are…
Aware that work is being done in the hospital…
Do not know workplace's approach
# of Narrative Responses
How effective do you believe that your primary workplace's approach
is to addressing issues of aggression and/or physical violence?
79
Near the end of the survey the RNs were asked if they had any other thoughts that they
would like to share about the issue of aggression and physical violence in hospitals and their
responses were robust and varied (as shown in Figure U). Twenty-seven of the RNs’ responses
included the theme that aggressive or physically violent patients or visitors are not held
accountable as one RN shared that there is a:
common feeling among staff is that verbal and physical assaults are not tolerated in
business, commerce, on airlines, etc. But because patients are medically ill, they need to
be cared for, so they are allowed to stay. We need more laws punishing patients if they
assault healthcare workers, and need to ban patients from the hospital (if they are repeat
offenders).

Twenty-four of the RNs reported that more training is needed for nurses such as teaching
strategies about de-escalation, managing violence/ aggression and/or self-defense as one RN
shared, “we have education about what to do in the case of an active shooter but not how to de-
escalate a situation with an angry patient or visitor which is much more common”.
Nineteen of the respondents reported that aggression and/or physical violence from
patients or visitors is increasing, more prevalent and/or getting worse and one RN explained that
“most people are shocked to find out that I was punched by a patient or that a patient and/or
visitor was verbally aggressive towards me”. Sixteen of the RNs’ responses included feeling
unsupported by hospital administration. Thirteen of the RNs’ responses included that aggression
or physical violence can be related to an increase in drug addiction in the community. Twelve
respondents expressed that these incidents are under-reported as one RN shared,
I think that it happens so often many people just ignore it happened or sweep it under the
rug. I have known of other people (who) have reported violence/ assault but patients
don’t get in trouble due to being under the influence of drugs or alcohol. However, most
recently a sexual assault had taken place and the staff member reported it appropriately
and the patient was found guilty.

80
Lateral violence between nurses and other nurses, MDs and others (described as verbal
and bullying) was identified as a problem in 10 of the RNs’ responses. One RN shared how the
profession of nursing influences our response to aggression or physical violence because as
nurses,
we are taught to be understanding and to put others first. I think that hinders us from
responding to aggression and violence as other professions do. I also think that no one
wants to believe that this happens to nurses since we are seen as caring and kind
professionals so outside of the profession people don’t necessarily see it as a problem.

Figure U. Major Themes from Narrative Responses to the Question about Additional Thoughts
about the Topic
0 5 10 15 20 25 30
Aggressive or Physically Violent Patients or
Visitors are Not Held Accountable
More Training is Needed for Nurses
Aggression and/or Physical Violence from Patients
or Visitors is: on the Increase, More Prevalent or…
Nurses Feel Unsupported by Hospital
Administration
Aggression or Physical Violence can be Related to
Increase in Drug Addiction in the Community
Incidents are Under-reported
Lateral Violence between nurses and other nurses,
MDs and others (described as verbal and…
Managing Aggressive or Physically Violent
Patients or Visitors is Considered to be Part of a…
Aggression or Physical Violence can be Related to
Mental Health Issues or Lack of Mental Health…
Important that Nurses Know when to get Help
# of Narrative Responses
Do you have any other thoughts that you would like to share ...
81
Conclusion
The results of this study support that there is a problem of violence experienced by RNs
working in hospitals in Massachusetts. Over 80% of the RNs surveyed reported having
experienced aggression and/or physical violence from a patient or visitor at least twice a year,
however only 19.8% of the RNs report these types of incidents most of the time or always (Table
6, Figure H and Figure I).
Although the results of this survey are presented in such a way to delineate specific
questions to assess knowledge, motivational or organizational influence, the actual responses
reflect the fluidity and connectedness within the KMO framework. Most of the findings cannot
be categorized solely in either knowledge, motivational or organizational categories. The
Conceptual Framework (Figure A) is a visual representation of how this problem of practice is
influenced by knowledge, motivation and organizational factors and reflects the dynamic
relationship between these KMO influences.
These results reveal rich and varied information that may help to address the problem of
violence experienced by nurses in hospitals. Although many themes were identified, the two
major themes recognized were the lack of reporting and low efficacy of the RNs. Chapter 5 will
include a discussion of the findings and recommendations for practice based upon knowledge,
motivational and organizational influences.

82
CHAPTER 5: DISCUSSION AND ORGANIZATIONAL RECOMMENDATIONS
Introduction
Chapter Five includes a discussion of the findings and implications for practice based
upon knowledge, motivational and organizational influences. The first section reviews the
purpose of the study, research questions and methodology. The second section includes the
discussion of findings. The third section examines the implications for practice. The fourth
section includes recommendations for future research. The chapter ends with final thoughts
about the evaluation of this problem of practice using the gap analysis dimensions of knowledge,
motivation, and organization.
Purpose of the Project
The purpose of this project was to complete an exploratory evaluation of nurses’
experiences and beliefs about violence in the workplace. The specific performance issue that
was explored was the violence experienced by Registered Nurses while working in a hospital in
Massachusetts. While a complete performance evaluation would have focused on all
stakeholders, for practical purposes the stakeholder group focused upon in this analysis included
RNs who were licensed in Massachusetts who work in hospitals. The questions that guided this
evaluation study addressing the knowledge and skills, motivation, and organization elements
were:
1. What is the nature of the RNs’ experiences in aggression and/or physical violence while
working in the hospital and how are these experiences shaped by knowledge, motivation
and organizational influences?
2. What are the barriers for an organization to measure and evaluate incidents of aggression
or physical violence by patients or visitors towards nurses?
83
3. What are the recommendations for organizational practice in the areas of knowledge,
motivation, and organizational resources?
The specific analytic approach that was used in assessing the problem of violence
experienced by RNs was the Gap Analysis Conceptual Framework (Clark & Estes, 2008). An
embedded mixed methods approach was used to explore the research questions. The specific
instrument used was a survey (see Appendix A for the survey instrument). The methodology and
analysis focused on knowledge, motivation and organizational elements that were related to the
problem of violence experienced by RNs working in hospitals in Massachusetts.
Discussion of Results and Findings
Major Themes
Lack of reporting. The survey results demonstrated that there is a significant gap
between the frequency of incidents of aggression or physical violence by patients or visitors
towards RNs and the actual reporting of these incidents by nurses. Although 83.2% of RNs
reported that on average they experience aggression or physical violence from patients or visitors
at least a couple of times a year, only 19.8% of RNs actually report these incidents most of the
time or always. These incidents of aggression or physical violence are rarely or never reported
by 54.5% of the RNs who responded (Table 6, Figure H and Figure I). Eighty-seven percent of
the RNs reported that their organization had a formal reporting process that can be used if a
patient or visitor is aggressive or physically violent as shown in Figure K. Fifty-nine percent of
the RNs reported that they have been trained about how to report when a patient is physically
violent.
Despite this report of knowledge of how to report these incidents, there is a lack of
reporting of incidents of aggression or physical violence by patients or visitors towards nurses.
84
Knowledge, motivation and organizational influences impact this problem of practice as
described in the Conceptual Framework (Figure A) which has guided this study. Thirty-one of
the RNs’ responses reflected that they believe that incidents of aggression or physical violence
are part of the job”, they “don’t take it personally” and/or they “move-on and/or get back to
work”. If nurses consider these incidents to be part of their job, then this may contribute to the
gap between incidents and reporting of the incidents. If aggression or physical violence by
patients or visitors was not seen as a problem and not reported, then it was unlikely that a
debriefing would occur as one RN explained, "It is something that is too often NOT reported,
unless physical harm is actually done to a nurse. The swearing, yelling, throwing things and
insults are usually not reported". Another RN shared "Many times I have kept situations like this
to myself; I don't talk about them a lot". Another RN further explained that:
Nurses believe that violence is part of their everyday work responsibilities. These
incidences are significantly underreported and therefore minimal action steps are taken to
address the issue. The reporting process is cumbersome and time consuming which
further discourages staff from reporting occurrences

An organizational cultural model influence was a belief within hospitals that instances of
physical violence by patients did not need to be reported unless there was an injury to the nurse
requiring care from Employee Occupational Health Services (EOHS) was assessed through both
fixed responses and open ended responses of RNs who completed the survey. One RN explained
“I believe safety reports are only if physical injuries occur – not if your feelings are hurt by
aggressive/ verbally abusive/ mistreatment from family/ visitors” while another stated “I feel
nursing staff can handle a demented patient who is squeezing or scratching”.
Low self-efficacy. The impact of emotion upon motivation was assessed and there were a
wide array of feelings experienced by RNs when a patient or visitor became aggressive or
physically violent toward him or her (Figure M). The most common emotions expressed were
85
the RNs feeling scared, afraid or fearful. The second most common emotion expressed by the
RNs was feeling angry. Some of these results were unexpected to this investigator, particularly
self-deprecating emotions such as 25 RNs reporting that when these incidents occur they feel
stupid, embarrassed, belittled, guilty, it’s my fault, sad, less, defeated, inferior and/or hurt
(Figure M). Nurses’ self-efficacy may be negatively impacted if they are taking responsibility
for the inappropriate actions or behavior of another individual whom they ultimately do not have
control over.
Despite many RNs reporting these types of feelings, there may be no debrief or even self-
reflection after these incidents if they are considered to be part of the nurse’s job. With a
deficiency in the metacognitive knowledge influence of reflection following these incidents, their
practice may not change or develop and a nurse’s self-efficacy may be lower. The metacognitive
knowledge influence of RNs having self-awareness of his or her emotions and how these
emotions may impact his or her response to incidents is also partly reliant upon the recognition
that aggression or physical violence by patients or visitors is a problem.
Self-efficacy in regards to RNs’ confidence in their ability to de-escalate a situation when
a patient or visitor became aggressive and their ability to protect themselves when a patient or
visitor became physically violent was assessed. On a scale of 0 to 10, zero being not at all
confident and ten being very confident, the mean response was 6.64 in RNs’ self-reports of
confidence in his or her ability to de-escalate an aggressive patient or visitor. On a scale of 0 to
10, the mean response was 5.93 in RNs’ self-report of confidence in his or her ability to protect
himself or herself if a patient or visitor became physically violent (Table 7 and Figure O).

86
Limitations and Suggestions for Future Research
There may have been limitations to this study which may have included respondent
truthfulness and the possibility that there may have been answers to the questions that a subject
would choose, but it was not listed as an option in those with fixed responses. This investigator
was not able to obtain a complete database of emails of all of the RNs in Massachusetts in order
to obtain a random sample that may be more reflective of the targeted stakeholders. A limitation
of this study was the sampling methodology, sample size and distribution. The use of snowball
sampling probably increased the size of the sample in the study, however based upon the
demographic data and size of the sample, the information from the survey cannot be completely
generalizable.
The survey was distributed electronically as opposed to the distribution of a paper survey
and this electronic platform for completing the survey may have limited the number of
respondents who were not technologically savvy. Survey respondents were also not able to “go
back” to the previous questions in the survey if they wanted to change or add to an answer. I
purposefully made this decision to decrease the possibility of the actual questions within the
survey having an influence on previous responses to questions, however this may also be a
limitation because respondents may have changed or added to their responses if they were able
to. It may be beneficial to explore the data from this study further using correlational statistical
analysis to determine if there were any relationships between demographic data and the
responses to individual questions or if there was a connection between the responses of
questions.
Future research may separate questions within the survey so that information is obtained
about a more specific situation. For example, rather than have a question that that includes
87
aggression and physical violence by a patient or visitor, it may be beneficial to ask individual
questions exploring the topics of: aggression from a patient, aggression from a visitor, physical
violence by a patient and physical violence by a visitor. Research in the future may include other
disciplines in the hospital as part of a sample such as MDs, Physical Therapists, Nursing
Assistants, etc.. and it would be interesting to explore a different healthcare setting such as Long
Term Care Facilities, Rehabilitation Hospitals, etc. . In addition, it would be essential to also
include identifying best practices in preventing and managing violence in healthcare settings as a
report by the National Advisory Council on Nurse Education and Practice (NACNEP) (2007) to
the U.S. Department of Health and Human Services and the US Congress recommended to
“provide resources for research on violence against nurses to determine effective prevention,
intervention, and management strategies”.
Recommendations for Practice
Knowledge Recommendation
Introduction. This section focuses recommendations to address knowledge-related
influences. These recommendations are pertinent to the achievement of the stakeholder goal of
RNs being able to describe what to do when a patient or visitor is aggressive and/or physically
violent. This analysis will include reviewed literature in terms of the type of knowledge that is
being described. Table 9 contains a summary of the assumed knowledge influences and
recommendations.

88
Table 9
Summary of Knowledge Influences and Recommendations
Assumed Knowledge
Influence: Cause, Need,
or Asset*

Validated
Yes, High
Probability,
or No
(V, HP, N)
Priority
Yes,
No
(Y, N)
Principle and Citation Context-Specific
Recommendation
Conceptual: Nurses need
to know what supports
are available to them if a
patient or visitor
becomes aggressive or
physically violent (D).

HP

Y
How individuals
organize knowledge
influences how they
learn and apply what
they know
(McCrudden, Schraw
& Hartley, 2006).
Provide nurses with
information about
what supports exist
within the hospital
and how to activate
those supports
included within
training and posted
in work units for
easy reference.
Nurses need to be able
to implement strategies
that may de-escalate a
situation when a patient
or visitor becomes
aggressive or physically
violent in the hospital
environment (P).

HP

Y
Modeling to-be-
learned strategies or
behaviors improves
self-efficacy, learning
and performance
(Denler, Wolters, &
Benzon). Effective
observational
learning is achieved
by first organizing
and rehearsing
modeled behaviors,
then enacting them
overtly (Mayer,
2011).
Provide training that
includes
demonstrations of
de-escalating an
aggressive or
physically violent
patient or visitor,
practice in small
groups and then
assess return
demonstrations from
nurses in training

Nurses need to know
how to reflect on their
own practice both in de-
escalating situations and
how effective their
interventions are when
responding to aggression
or physical violence to
protect themselves and
others(M,1).

HP

Y

The use of
metacognitive
strategies facilitates
learning (Baker,
2006).

Implement real-time
debriefs facilitated
by a supervisor with
staff involved to
discuss events and
reflect on practice.

89
(continued)Summary of Knowledge Influences and Recommendations
Assumed Knowledge
Influence: Cause, Need,
or Asset*

Validated
Yes, High
Probability,
or No
(V, HP, N)
Priority
Yes,
No
(Y, N)
Principle and Citation Context-Specific
Recommendation
Nurses need to have
self-awareness about
how emotions that they
may experience may
influence their own
behavior when
confronted by situations
of aggression or physical
violence (M,2).
HP Y
Self-regulatory
strategies enhance
learning and
performance (APA,
2015: Dembo &
Eaton, 2000; Denler,
et al., 2009).
During debriefs,
include opportunity
for nurses to reflect
upon their own
emotions and how it
may or may not have
impacted their
response. In
addition, follow-up
later with nurse
manager individually
for a “check in” in
the event the nurse
may need additional
support

*Indicate knowledge type for each influence listed using these abbreviations: (D)eclarative;
(P)rocedural; (M)etacognitive.
Conceptual knowledge. An assumed conceptual knowledge influence is that nurses
must know what support or assistance is available to them within the hospital if a patient or
visitor becomes aggressive or physically violent. This influence has a high probability of being
validated and is a priority. The learning solution principle is to understand how individuals
organize knowledge influences how they learn and apply what they know (Schraw &
McGrudden, 2006). The recommendation for practice is to provide nurses with information
about what supports exist within the hospital and how to activate those supports through training
and also posted in work areas for easy reference.
In addition, by increasing germane cognitive load by engaging the learner in meaningful
learning and schema construction facilitates effective learning (Kirshner, Kirshner & Paas,
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2006). The proposed solution may include using a real-life example from a hospital and describe
a situation when a patient or visitor was verbally abusive, threatening or being physically violent
and describe the steps that a nurse would take in responding including activating a silent alarm to
call security and notifying a supervisor. Mayer (2011) describes how germane cognitive load
may be increased by presenting information in the context of a familiar situation and connecting
new information with prior knowledge.
Procedural knowledge. Nurses need to implement strategies that may de-escalate a
situation when a patient or visitor becomes aggressive or physically violent in the hospital
environment is an assumed procedural knowledge influence. This influence has a high
probability of being validated and is a priority. The learning solution principle of Denler,
Wolters, & Benzon (2006) is that modeling to-be-learned strategies or behaviors improves self-
efficacy, learning and performance. Effective observational learning is achieved by first
organizing and rehearsing modeled behaviors, then enacting them overtly (Mayer, 2011). The
recommendation for practice is to provide training that includes demonstrations of de-escalating
an aggressive or physically violent patient or visitor, practice in small groups and then assess
return demonstrations from the nurses in the training.
The solution would also include managing the intrinsic load by segmenting complex
material into simpler parts and pre-training, among other strategies enables learning to be
enhanced (Kirshner, Kirshner & Paas, 2006). Mayer (2011) also described the importance of
presenting information in manageable parts. Holleran (2006) recommended a prevention strategy
that included “training that includes methods to recognize potentially violent patients, skills to
defuse potentially violent situations, and instructions to ensure personal safety” (p. 524). The
proposed solution may include presenting the information singularly about how to recognize
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early signs of agitation or hostility and consider using multimedia presentations during training
including facial expressions or body language during a verbal discussion.
In addition to sharing information in conversation and in print, the proposed solution may
include showing the nurses a few (acted) video or live vignettes demonstrating aggression or
physical violence toward health care workers and the effective techniques used to help de-
escalate the situation. After each vignette, the instructor may pause and have a group discussion
about what they identified as effective ways to help de-escalate a situation. After the group
discussion, the instructor may ask for volunteers to participate in a vignette and practice using
the de-escalation techniques. Welch (2008) suggested communication training as a strategy to
prevent violence in the Emergency Department of a hospital:
Active listening can often diffuse a situation. If the patient or upset family member
perceives that the caregiver is concerned and involved, this may diffuse the situation.
Using first person expressions (I or we) is less inflammatory than second person (you)
statements….80% of communication is nonverbal and body language can escalate a
difficult encounter. Experts recommend that you adopt a very open posture as opposed to
closing your arms across the chest or standing with hands on hips. They also caution
against pointing at the angry individual. The best stance is with arms at your sides,
looking the person in the eye but at a slight angle, not dead-on, because it is less
confrontational (p.4).
Metacognitive knowledge 1. One of the metacognitive knowledge influences is that
nurses need to be able to reflect on their own practice both in de-escalating situations and how
effective their interventions are when responding to aggression or physical violence to protect
themselves and others. This influence has a high probability of being validated and is a priority.
The learning solution principle is that the use of metacognitive strategies facilitates learning
(Baker, 2006). The recommendation for practice is to implement real-time debriefs facilitated by
a supervisor with staff involved to discuss events and reflect on practice.
92
After completing the training activities described as part of factual, conceptual and
procedural knowledge, the instructor may ask the nurses to once again reflect upon a situation
when a patient or visitor was verbally abusive, threatening or physically violent and do they now
think that there is anything that they would have done differently. As Baker (2006) explained,
metacognition may be promoted by providing opportunities for learners to debrief the thinking
process upon completion of learning a task. Interestingly, Mantzoukas & Jasper (2008)
described the results of their qualitative study exploring types of nursing knowledge and they
classified the types into: “personal practice knowledge, theoretical knowledge, procedural
knowledge, ward cultural knowledge and reflexive knowledge” (p.318).
Metacognitive knowledge 2. Another metacognitive knowledge influence is that nurses
need to have self-awareness about how emotions they may experience may influence their own
behavior when confronted by situations of aggression or physical violence. This influence has a
high probability of being validated and is a priority. The learning solution principle is that self-
regulatory strategies enhance learning and performance (APA, 2015; Dembo & Eaton, 2000;
Denler, et al., 2009). The recommendation for practice is that during debriefs, including an
opportunity for nurses to reflect upon their own emotions and how it may or may not have
impacted their response. Emotions impact whether one engages in choice, persistence and effort
(Rueda, 2011). In addition, follow-up with the nurse manager individually for a “check in” in the
event that the nurse may need additional support may be included as part of the recommendation
for practice.
Motivation Recommendations
Introduction. This section will focus on recommendations to address motivation-
related influences that are anticipated to have a high probability of being validated since data
93
collection is still in process. These recommendations are pertinent to the achievement of the
stakeholder goal of nurse being able to describe what to do when a patient or visitor is aggressive
and/or physically violent. This analysis will include reviewed literature in terms of the
motivational influence that is being described. Table 10 contains a summary of the assumed
knowledge influences and recommendations.

94
Table 10
Summary of Motivation Influences and Recommendations
Assumed Motivation
Influence: Cause, Need,
or Asset*

Validated
Yes, High
Probability,
No
(V, HP, N)
Priority
Yes, No
(Y, N)
Principle and Citation Context-Specific
Recommendation

Emotions: Fear and
Anxiety: Nurses may
experience fear or
anxiety in their daily
work
Y Y Positive emotional
environments support
motivation (Clark &
Estes, 2008).
Provide an
opportunity during
debriefs for nurses
to reflect upon
their own emotions
about the situation
and follow-up
later with nurse
manager
individually for a
“check in” in the
event the nurse
may need
additional support

Provide manager
training in regards
to providing
support and
therapeutic
responses to
victims

Self-Efficacy: Nurses
need to have
confidence in their
ability to implement
interventions that will
have the desired effect
of successfully de-
escalating or managing
potentially violent
situation
Y Y Modeled behavior is
more likely to be
adopted if the model
is credible, similar,
and the behavior has
functional value
(Denler et al, 2009).
Provide training
through
demonstration and
modeling of
strategies to de-
escalate an
aggressive or
physically violent
patient or visitor.

95
Emotions. An assumed motivational influence is that nurses may experience fear or
anxiety in their daily work. This influence has a high probability of being validated and is a
priority. The motivation solution principle is based upon Clark and Estes (2008) description that
positive emotional environments support motivation. The recommendation for practice is to
provide an opportunity during debriefs for nurses to reflect upon their own emotions about
situations and follow-up later with a “check-in” with the nurse manager in case the nurse needs
additional support. To address some of the self-deprecating feelings expressed by some of the
RNs, these debriefs may also include re-assurance and clarification that when a patient or visitor
becomes aggressive or physically violent, it is not a reflection of the RN’s ability or character.
Ulman, et al (2007) found that “the association typically observed between victim self-blame and
PTSD symptoms may be partially due to the effects of negative social reactions from others”
(p.23). Therefore, in addition managers may need training in regards to the appropriate way to
support a nurse who was a victim of aggression or physical violence to ensure that responses are
therapeutic.
It must be recognized that the significant influence that fear and anxiety can have on
those who are confronted with a verbally abusive, threatening or physically violent patient or
visitor. Holleran (2006) shared a detailed description of the background of violence specifically
in the Emergency Departments of hospitals:
It is important to note that unlike most workplaces, the emergency department must
accept anyone who presents himself or herself for care. ED nurses and other staff are
disproportionately exposed to violence, including cases of human abuse and neglect,
cases of murder and suicide, aggressive behaviors that are the result of mental illness, and
traumatic events such as motor vehicle collisions (p.523).

Self-Efficacy. . An assumed motivational influence is that nurses need to have
confidence in their ability to implement interventions that will have the desired effect of
96
successfully de-escalating or managing potentially violent situations. This influence has a high
probability of being validated and is a priority. The motivation solution principle is that modeled
behavior is more likely to be adopted if the model is credible, similar, and the behavior has
functional value (Denler et al, 2009). The recommendation for practice is to provide training
through demonstration and modeling of strategies to de-escalate an aggressive or physically
violent patient or visitor.
Self-efficacy is a factor in the transfer of training and refers to a person’s belief in their
ability to perform (Grossman and Salas, 2011). Nurses need to have confidence in their ability to
implement interventions that will have the desired effect of successfully de-escalating or
managing a potentially violent situation. Mantesso, Petrucka and Bassendowski (2008) found
that “Reflective practice encompasses a peer feedback process that, when undertaken by nurses,
potentially creates a more holistic picture of their nursing capabilities, strengths, and areas for
growth” (p.201). Similarily, Adriaenssens, DeGucht and Maes (2015) found that “high
perceived job control was related to higher levels of work engagement and to lower levels of
burnout” (p.157) in emergency nurses.
Organization Recommendations
Introduction. This section will focus on recommendations to address organization-
related influences that are anticipated to have a high probability of being validated since data
collection is still in process. These recommendations are pertinent to the achievement of the
stakeholder goal of RNs being able to describe what to do when a patient or visitor is aggressive
and/or physically violent. This analysis will include reviewed literature in terms of the type of
organizational influence that is being described. Table 11 contains a summary of the assumed
organizational influences and recommendations.
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Table 11
Summary of Organization Influences and Recommendations
Assumed
Organization
Influence: Cause,
Need, or Asset*

Validated
Yes, High
Probability,
No
(V, HP, N)
Priority
Yes,
No
(Y, N)
Principle and Citation

Context-Specific
Recommendation

There is a belief
within hospitals that
aggression or
physical violence by
a confused or
agitated patient is
“just part of the job”
(CM, 1).

HP

Y

Understanding the
relationship between
ethical practice and
accountability helps to
avoid dilemmas
associated with
meeting organizational
goals (Biesta, 2004;
Dubnick, 2003; Strike,
Haller & Soltis, 2005).

Provide clarification
to staff that although
the actions or
behavior of a patient
may be due to a
medical or
psychiatric
condition,
aggression or
physical violence is
not acceptable and
must be reported.
There is a belief
within hospitals that
instances of physical
violence by patients
do not need to be
reported unless there
is an injury to the
nurse requiring care
from Employee
Occupational Health
Services (EOHS)
(CM, 2).
HP Y Building the capacity
of an organization is
crucial in improving
the institution and its
accountability systems
(Wohlstetter, Malloy,
Hentschke, 2004;
Norton, Grubb &
Badway, 2005)..

Explain to staff the
importance of
reporting all
incidents of physical
violence and how
this is important to
promote
organizational
improvement.
There is a lack of
required training for
nurses about how to
de-escalate someone
who is aggressive or
how to respond and
to protect oneself if
a patient or visitor
becomes physically
violent (CS, 1).
HP Y Organizational
effectiveness increases
when leaders ensure
that employees have
the resources needed to
achieve the
organization’s goals
(Waters, Marzano &
McNultry, 2003).
Provide sufficient
resources to
establish and
implement a training
program for all
nurses in the
organization and
going forward
include this training
in new employee
orientation.

98

(continued) Summary of Organization Influences and Recommendations
Assumed
Organization
Influence: Cause,
Need, or Asset*

Validated
Yes, High
Probability,
No
(V, HP, N)
Priority
Yes,
No
(Y, N)
Principle and Citation

Context-Specific
Recommendation
There is a lack of a
formal process to
report incidents of
aggression or
physical violence by
patients or visitors
so the incidents may
be measured and
analyzed (CS, 2).
HP Y Accountability is
increased when
organizations adopt a
balanced scorecard
approach to assessing
performance
(Bensimon, 2007).
Measurement of
learning and
performance are
essential components
of an effective
accountability system
capable of improving
organizational
performance (Dowd &
Shieh, 2013; Golden,
2006; Marsh & Farrell,
2015).
Implement an
efficient way in
which staff can
report incidents of
aggression or
physical violence by
patients or visitors
that is captured by
one central database
in the hospital so
data can be collected
and analyzed by
hospital leadership
to determine the
scope of the problem
and if interventions
are successful.
*Type of Organizational Influences (CM) Cultural Model and (CS) Cultural Setting

Cultural model influence 1. A cultural model influence is that there is a belief within
hospitals that aggression or physical violence by a confused or agitated patient is “just part of the
job”. This influence has a high probability of being validated and is a priority. The organization
solution principle calls for understanding the relationship between ethical practice and
accountability helps to avoid dilemmas associated with meeting organizational goals (Biesta,
2004; Dubnick, 2003; Strike, Haller & Soltis, 2005). The recommendation for practice is to
provide clarification to staff that although the actions or behavior of a patient may be due to a
99
medical or psychiatric condition, aggression or physical violence toward staff is not acceptable
and must be reported.
Cultural model influence 2. Another cultural model influence is that there is a belief
within organizations that instances of physical violence by patients do not need to be reported
unless there is an injury to the nurse that requires him or her to receive care from Employee
Occupational Health Services (EOHS). This influence has a high probability of being validated
and is a priority. The organization solution principle is that building the capacity of an
organization is crucial in improving the institution and its accountability systems (Wohlstetter,
Malloy, Hentschke, and Smith, 2004; Norton Grubb & Badway, 2005). The recommendation for
practice is to explain to staff the importance of reporting all incidents of physical violence and
how this is important to promote organizational improvement.
Cultural setting influence 1. A cultural setting influence is that there is a lack of
required training for nurses about how to de-escalate someone who is aggressive or how to
respond and to protect oneself if a patient or visitor becomes physically violent. This influence
has a high probability of being validated and is a priority. The organization solution principle is
that organizational effectiveness increases when leaders ensure that employees have the
resources needed to achieve the organization’s goals (Waters, Marzaon & McNultry, 2003). The
recommendation for practice is to provide sufficient resources to establish and implement a
training program for all nurses in the organization and going forward include this training in new
employee orientation.
Cultural setting influence 2. Another cultural setting influence is the lack of a formal
process to report incidents of aggression or physical violence by patients or visitors so the
incidents may be measured and analyzed. This influence has a high probability of being
100
validated and is a priority. The organization solution principle is based upon Bensimon (2007)
who reported that accountability is increased when organizations adopt a balanced scorecard
approach to assessing performance. Another organization solution principle is that measurement
of learning and performance are essential components of an effective accountability system
capable of improving organizational performance (Dowd & Shieh, 2013; Golden, 2006; Marsh &
Farrell, 2015). Hospitals may also want to consider using a type of hazard risk matrix that may
help predict the probability and severity of violence within a specific area of the hospital (OSHA,
2015). This type of tool may be another way to help to allocate resources appropriately to
prevent physical and psychological harm to health care workers (Arnetz, Hamblin, Ager, et al,
2014; McPhaul, London, Murrett, Flannery, Rosen, and Lipscomb, 2008). The recommendation
for practice is to implement an efficient way in which staff can report incidents of aggression or
physical violence by patients or visitors that is captured by one central database in the hospital so
data can be collected and analyzed by hospital leadership to determine the scope of the problem
and if interventions are successful.
Integrated Implementation and Evaluation Plan
Implementation and Evaluation Framework
The New World Kirkpatrick Model (2016) consists of four components of training
evaluation. Within this model, it is necessary to first identify “the degree to which targeted
program outcomes occur and contribute to the organization’s highest-level result” (p.39). This
first step is referred to as Level 4: Results, and describes the desired outcomes, how these results
will be evaluated and how this connects with an organization’s mission or how it is useful
(Kirkpatrick & Kirkpatrick, 2016). The next step is to evaluate “the degree to which
participants apply what they learned during training when they are back on the job” (p.39). This
101
step is called Level 3- Behavior and is considered to be the most important level to evaluate
(Kirkpatrick & Kirkpatrick, 2016). Kirkpatrick & Kirkpatrick (2016) explained that Level 2:
Learning evaluation is “the degree to which participants acquire the intended knowledge, skills,
attitude, confidence, and commitment based on their participation in the training” (p.39). Level
1- Reaction evaluation of training is “the degree to which participants find the training favorable,
engaging, and relevant to their jobs” (p.39).
Organizational Purpose, Need and Expectations
The purpose of this project is to evaluate the nature of the RNs’ experience as it relates to
aggression and physical violence while working in Massachusetts hospitals and to evaluate the
degree to which Massachusetts Hospitals are successfully implementing a violence prevention
program. The Massachusetts Hospital Association (MHA) (2016) represents most of the
hospitals within the state of Massachusetts and explains that the basic mission of its members is
caring for people. The American Nurses Association ([ANA], 2016) explained that
Nursing is the protection, promotion, and optimization of health and abilities, prevention
of illness and injury, facilitation of healing, alleviation of suffering through the diagnosis
and treatment of human response, and the advocacy in the care of individuals, families,
groups, communities, and populations (ANA, np).

In order for RNs to achieve the mission of providing nursing care for patients in hospitals
he or she must be able to respond appropriately when a patient or visitor becomes aggressive or
physically violent. The goal that reflects the problem of violence experienced by RNs in
hospitals is that by December 2018, all RNs working in hospitals in Massachusetts will articulate
at least three interventions they may use when confronted by patients or visitors who are
aggressive or physically violent.

102
Level 4: Results and Leading Indicators
The achievement of the stakeholder goal describes a Level 2 - Learning evaluation
component of RNs being able to articulate at least three interventions they may use when
confronted by patients or visitors who are aggressive or physically violent. However a Level 4-
Results evaluation component would include the outcomes from achieving the stakeholder goal
from the perspective of both internal and external measures.
External leading indicators. The outcomes that would be expected if the stakeholder
goal were achieved include reporting data to the Occupational Safety and Health Administration
(OSHA) in regards to workplace violence. It would be expected that there may be an initial
increase in reports of episodes of workplace violence and/or employee injuries from patients or
visitors upon completion of the training and successful implementation of interventions. The
ultimate goal would be that over time, the number of incidents that occur that are reported to
OSHA would decrease reflecting successful implementation of de-escalation techniques and/or
ways of protecting oneself in these situations. Another expected outcome would be a decrease in
local media reports of patient or visitor aggression and/ or physical violence toward RNs as the
actual number of occurrences decreases (see Table 12).

103
Table 12
Outcomes, Metrics, and Methods for External Outcomes
Outcome Metric(s) Method(s)
External Outcomes
Initial increase in
reporting of episodes of
patient and/or visitor
physical violence by RNs
# of incidents of physical
violence by visitors
# of incidents of physical
violence by patients
Through formal process of
reporting within hospital and
then reported out quarterly to
the Occupational Safety and
Health Administration (OSHA).

Decrease in reported
episodes of physical
violence by patients or
visitors toward RNs
# of incidents of physical
violence by visitors
# of incidents of physical
violence by visitors
Through formal process of
reporting within hospital and
then reported out quarterly to
OSHA.

Decrease in amount of RN
injuries resulting from
physical violence by
patients or visitors
# of RN injuries resulting from
physical violence by patients or
visitors
Through formal process of
reporting within hospital such as
Employee Occupational Health
Services (EOHS) and then
reported to OSHA as required

Decrease in local news
stories of violence in
hospitals
# of incidents Public relations or
communications department
monitors local media coverage.

Internal leading indicators. The outcomes would include an initial increase in the
reporting of events of patient or visitor aggressiveness or physical violence in the short term
demonstrating that RNs are actually reporting these events. The results of this study found that
83.2% of RNs reported on average, experiencing aggression or physical violence by visitors or
patients at least a couple of times a year, however only 9.27% of respondents always report these
events and 10.48% report these events most of the time.
In the longer term a leading indicator would be a decrease in the amount of occurrences
of physical violence by patients or visitors toward RNs. If the stakeholder goal was achieved
and interventions implemented, the Level 4 expected outcome may be a decrease in occurrences
104
of aggression and/or physical violence by patients or visitors towards RN. Internally, this could
be measured by tracking reported events. Another leading indicator of success would be the
outcome of decreased RN injuries from patient or visitor physical violence. This outcome may
indicate that RNs are operationalizing de-escalation techniques and ways to protect themselves
that were learned if a patient or visitor becomes physically violent.
Another outcome if the stakeholder goal is achieved would include the results from
follow up focus groups, interviews and/or surveys in which RNs will self-report higher self-
confidence in his/ her ability to de-escalate a patient or visitor who becomes aggressive or
physically violent. In the same follow up focus groups, interviews and/or surveys, RNs will
articulate at least three interventions they may use if a patient or visitor becomes aggressive or
physically violent which is described in Table 13.

105
Table 13
Outcomes, Metrics, and Methods for Internal Outcomes
Outcome Metric(s) Method(s)
Internal Outcomes
Initial increase in reporting of
episodes of patient and/or
visitor aggression or physical
violence by RNs
# of incidents of physical
violence by visitors
# of incidents of aggression by
visitors
# of incidents of physical
violence by patients
# of incidents of aggression by
patients

Through formal process of
reporting within hospital and
then reported out quarterly to
OSHA
Decrease in reported episodes
of physical violence by
patients or visitors toward
RNs
# of incidents of physical
violence by visitors
# of incidents of physical
violence by patients
Through formal process of
reporting within hospital and
then reported out quarterly to
OSHA
Decrease in amount of RN
injuries resulting from
physical violence by patients
or visitors
# of RN injuries resulting
from physical violence by
patients or visitors
Through formal process of
reporting within hospital such
as Employee Occupational
Health Services (EOHS) and
then reported to OSHA as
required

Increase in RNs’ self-efficacy
in regards to his/ her ability to
de-escalate an aggressive or
physically violent patient or
visitor

Self-reported confidence
using scale 0-10
Anonymous surveys
distributed to RNs before
intervention and then post-
intervention at 3 months, 6
months and 1 year after
intervention

Ability of RNs to recall at
least three interventions they
may use if a patient or visitor
becomes aggressive and/or
physically violent
Open ended answers to
question asking RN to
describe at least 3 responses or
interventions that he/ she
could use if a patient or visitor
becomes aggressive and/or
physically violent
Anonymous surveys with
open ended question,
distributed to RNs before
intervention and then post-
intervention at 3 months, 6
months and 1 year after
intervention

106
Level 3: Behavior
Critical behaviors. The critical behaviors required for the achievement of the
stakeholder goal include the RN reflecting upon events to evaluate his/ her own performance and
emotions experienced and the hospital’s culture sustaining the belief that all incidents of physical
violence must be formally reported regardless of the patient’s medical diagnosis or intent. Table
14 outlines the critical behaviors, metrics methods and timing for evaluation of the achievement
of the stakeholder goal.

107
Table 14
Critical Behaviors, Metrics, Methods, and Timing for Evaluation
Critical Behavior Metric(s)
Method(s)
Timing
1.Demonstrate that
aggression or physical
violence by patients
or visitors is not an
expected part of the
RN’s job
RNs will report all
incidents of physical
violence by patients
or visitors
Survey of RNs asking
the frequency that they
experience physical
violence during the past
3 months and compare
this # to the actual
formal reports
Anonymous survey of
RNs before the
intervention and then
post-intervention at 3
months, 6 months and
1 year after
intervention
2. Ability to reflect
upon
incidents as evidenced
by participating in
debriefs following
situations when
patients or visitors are
aggressive and/or
physically violent
RNs will debrief
shortly after
episodes of
aggression or
physical violence
with colleagues
he/she is working
with that shift.
Survey of RNs asking
them what they do after
an incident and
specifically look for
answers such as
debriefing with
colleague, self-
reflection, time away
from the unit to take a
break, etc.
Anonymous survey of
RNs before the
intervention and then
post-intervention at 3
months, 6 months and
1 year after
intervention
3. Take opportunities
to debrief and seek
out additional
supports following
every episode of
physical violence
from a patient or
visitor
RNs will meet with
Nurse Manager or
designee within 1
week following an
episode to debrief
and be given
references for
additional support if
needed
Review follow-ups of
events when a patient or
visitor was physically
violent to ensure that
Nurse Manager or
designee met with RN
Meeting with Nurse
Manager or designee
after each reported
event of physical
violence
4. Ability to
operationalize at least
1 strategy during
episodes when a
patient or visitor
becomes aggressive
and/or physically
violent
When RNs
complete Incident
Reports for episodes
of aggression or
physical violence,
he/she will
document strategies
that were used in
response to the
event

Standardize Incident
Reports so that they not
only allow for a
description of the event,
but a place for the staff
member to document
his/her responses or
interventions
After each event, an
Incident Report
should be completed
and monthly review
of what (if any)
responses or
interventions were
documented by the
staff member
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Table 14 (continued)
Critical Behaviors, Metrics, Methods, and Timing for Evaluation
Critical Behavior Metric(s)
Method(s)
Timing

5. Demonstrate an
understanding of what
supports exist within
the hospital that they
may access when a
patient or visitor
becomes aggressive
and/or physically
violent
RNs will seek out
assistance from
other RNs or
departments within
the hospital when an
event occurs
Standardize Incident
Reports so that they not
only allow for a
description of the event,
but a place for the staff
member to document
his/her responses or
interventions which may
include seeking support
or assistance from others
After each event, an
Incident Report
should be completed
and monthly review
what (if any)
responses or
interventions were
documented by the
staff member

Required drivers. The required drivers that will support the critical behaviors necessary
to achieve the stakeholder outcomes are categorized as reinforcing, encouraging or rewarding as
summarized in Table 15. It is necessary that Hospital Administrators supply sufficient resources
to support an initial training of RNs in de-escalation strategies and other ways to respond to
aggression or physical violence and then to plan to allocate resources annually in the budgeting
process for annual training. Another reinforcing driver is how Hospital Administration will
review the results of RN surveys and findings from Incident Reports (as described in Table 15)
and then provide targeted re-enforcement of specific areas where improvement is needed via
newsletters, unit based staff meetings and incorporated into content of the annual training.

109
Table 15
Required Drivers to Support Critical Behaviors
Method(s) Timing
Critical Behaviors Supported
1, 2, 3 Etc.
Reinforcing
Hospital Administration will provide
resources to support the implementation
of an initial training of RNs (and then an
annual re-enforcement training) in de-
escalation strategies and other responses
to aggression and/or physical violence

Initial and then
annual
1,2,3,4,5
Hospital Administration will review the
results of RN surveys and findings from
Incident Reports (as described in Table 6)
and then provide targeted re-enforcement
of specific areas where improvement is
needed via newsletters, unit based staff
meetings and incorporated into content of
annual training

Ongoing 1,2,3,4,5
During debriefs with RNs following
events, Nurse Managers will provide
constructive feedback as needed in
regards to the RN’s response to an event

Ongoing 1,2,3,4,5
Encouraging
During debriefs with RNs following
events, Nurse Managers will provide
emotional support to RNs

Ongoing 1,2,3
Rewarding
During debriefs with RNs following
events, Nurse Managers will express
gratitude that the RN reported the
incident

Ongoing 1
During staff meetings, Nurse Managers
will review incidents that have occurred
during the past month (see re-enforcing
above) and publicly acknowledge RNs
for reporting the events and highlighting
the positive aspects of the team’s
response during the situation
Monthly 1,2,4,5
110
In addition, another reinforcing method will occur when Nurse Managers provide
constructive feedback as needed during debriefs with RNs following events. During the
debriefs, the Nurse Managers will also incorporate an encouraging driver of providing emotional
support to RNs following an event and information on how he/she may choose to seek out
additional support from an Employee Assistance Program (EAP) or resources available within
the hospital.
The debriefing sessions will also include rewarding drivers such as the Nurse Managers
expressing gratitude that the RN reported the event. During staff meetings, Nurse Managers will
incidents that have occurred during the past month and publicly acknowledge RNs for reporting
the events and highlighting the positive aspects of the team’s response during the situation
Monitoring and organizational support. The critical behaviors and required drivers
that are monitored for performance in the above section assume that the recommendations at the
organizational level were implemented. In order to achieve both internal and external desired
outcomes, the organizational supports must be implemented.
Level 2: Learning
Learning goals. Following the implementation of the organizational supports including
RN completion of Program to respond to aggression and/or physical violence in the hospital, the
RN stakeholders will be able to:
1. Identify what supports are available in the hospital that can assist them if a patient
or visitor becomes aggressive and/or physically violent. (C)
2. Implement strategies that may help to de-escalate a situation when a patient or
visitor becomes aggressive and/or physically violent. (P)
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3. Protect themselves and others if a patient or visitor becomes aggressive and/or
physically violent. (P)
4. Report all incidents of physical violence by patients or visitors regardless of
motive (i.e., reporting incidents that are inflicted by someone whose behavior is believed
to be related to a medical or psychiatric diagnosis). (P).
5. Debrief with colleagues and/or supervisor immediately following an event when a
patient or visitor becomes aggressive or physically violent to reflect upon their own
practice in de-escalating or responding to a situation. (M1)
6. Reflect upon their own emotions in regards to the event and how emotions may
have influenced his/her behavior when responding to the situation. (M2)
Program. The learning goals listed in the previous section will be achieved through the
completion of a program designed to teach RNs the background of aggression and physical
violence by patients or visitors in hospitals, prevention, early recognition, response and reporting
of events. The program will be blended including completion of a pre-test (see Appendix D),
assigned readings before the program, in-person lecture, in-person observations and practice.
The pre-test will be given 3 to 4 weeks before an RN attends the program to assess
knowledge, motivational and organizational influences as they relate to aggression or physical
violence by patients or visitors (Appendix D). Assigned readings will be sent to each RN
participant 2 weeks before the program including topics such as a general overview of aggression
and physical violence in hospitals, strategies for prevention, de-escalation and other responses
that may be used by the RN. The content of the day of the program in outlined in Appendix H.
Components of learning. The components of learning for the program include items
specifically related to declarative knowledge, procedural skills, attitude, confidence and
112
commitment (Table 16). To assess declarative knowledge, procedural knowledge, and self-
efficacy, a pre-test will be administered 3 to 4 weeks before the program (Appendix D).
Assigned readings will be shared with program participants 2 weeks prior to the program.
Table 16
Components of Learning for the Program.
Method(s) or Activity(ies) Timing
Declarative Knowledge “I know it.”
Pretest and posttest of strategies that may be used by the RN and
supports that are available in the hospital

Before, during and after
the training and then
annually.
Observation of an expert RN responding to a scenario during
training and then having a group discussion during the training
noting what was good and what could be improved

Initial training and then
annually
Presentation of scenarios during training and group discussion about
how the RN may respond including seeking out other support
Initial training and then
annually
Procedural Skills “I can do it right now.”
Each RN will participate in a practice scenario and articulate and/or
demonstrate his/her responses or actions and then a group
discussion with feedback about what went well and what may have
been done differently

Initial training and then
annually
In the Immediate Evaluation following the program and the Delayed
Evaluation, RNs will be asked specific questions regarding
procedural knowledge.
Initial training and then
annually
Attitude “I believe this is worthwhile.”
Group discussions about the incidents and consequences of
aggression and/or physical violence by patients or visitors toward
nurses and the importance of reporting events and being prepared to
respond appropriately

Initial training, at staff
meetings and then
annually
During staff meetings, review of incidents including what responses
or actions were taken and any positive outcomes (ie, patient and
staff not injured, visitor stepped back and stopped shouting, etc.)
At staff meetings
Confidence “I think I can do it on the job.”
Group discussion about feelings that may arise when a patient or
visitor becomes aggressive or physically violent and sharing with
one another successful coping strategies

Initial training, at staff
meetings and annually in
training
RNs self-reporting successful implementation of strategies and/or
seeking out supports when an event occurred
Initial training, at staff
meetings and annually in
training

113
Table 16 (continued)
Components of Learning for the Program.
Method(s) or Activity(ies) Timing
RNs self-reporting how confident he/she feels responding to a
situation when a patient or visitor is aggressive and/or physically
violent
Pre-training test, during
training, post training and
annually using likert score
1-10.
Commitment “I will do it on the job.”
RN self-reports of implementation of strategies/ seeking out support
via Incident Reports

ongoing
RN responses in Immediate Evaluation indicating how likely he/she
is to use strategies in practice

after initial training
RN responses in an annual survey asking how frequently the RN
reports incidents of aggression or physical violence by patients or
visitors.
annually

Declarative knowledge. The learning of declarative knowledge will be reinforced
throughout the day of the program as participants observe expert RNs respond to different
scenarios. The RNs will then participate in a group discussion about what they identified were
good responses and what could be improved. The scenarios and group discussions will also
reinforce what supports available to them in the hospital in the event that a patient or visitor
becomes aggressive or physically violent.
Procedural skills. A component of the learning of procedural skills will occur when each
RN participates in a practice scenario and role play. The RN will articulate and/or demonstrate
their responses during the scenario and then there will be a group discussion with feedback about
what went well and what may have been done differently. During the Immediate Evaluation
following the program (Appendix E) and the Delayed Evaluation (Appendix F) the RNs will be
asked specific questions regarding procedural knowledge.
Attitude. Presentations, readings, and group discussions will describe incidents and
possible consequences of aggression or physical violence toward nurses in hospitals and an
114
emphasis will be placed upon the importance of reporting such events and being prepared to
respond appropriately. During staff meetings, Nurse Managers will review incidents of patient
or visitor aggression or physical violence including what responses or actions were taken and any
positive outcomes (i.e., patient and staff not injured, visitor stepped back and stopped shouting at
the nurse, etc.).
Confidence. In addition to data obtained from Immediate and Delayed Evaluations, there
will be group discussions during the program about feelings that may arise when a patient or
visitor becomes aggressive or physically violent and sharing with one another successful coping
strategies. During the group discussions, RNs may self-report how they successfully
implemented a strategy to de-escalate a patient or visitor and/or what supports they contacted to
assist with a situation. In the pre-test, Immediate and Delayed Evaluations and then in the annual
RN survey, RNs will self-report how confident they feel when responding to a situation when a
patient or visitor is aggressive or physically violent.
Commitment. The RN responses in the Immediate and Delayed Evaluations will indicate
how likely they are to use the strategies learned in the program in practice. A learning
component will be the actual self-reports of RNs implementing strategies and/or seeking out
appropriate supports when an incident occurs via the formal reporting process. The responses of
RNs in the annual survey asking how frequently they report incidents of aggression or physical
violence by patients or visitors would be expected to increase if learning is successful. Table 17
summarizes these learning components including the timing of such methods and/or activities.
Level 1: Reaction
Level 1 of the New World Kirkpatrick Model (2016) evaluation of training will include
measurement of engagement, relevance and customer satisfaction. Attendance records are a
115
component of measuring engagement at the initial trainings and annual trainings. Ensuring that
instructors ask meaningful questions during the program and determining the level of RN
participation in group discussions and training will be assessed through observations of Program
Lead Trainer and in responses within the Immediate Evaluations (Appendix E). Relevance to the
participants’ work will be assessed throughout the training and specifically asking before or after
each break if so far in the program has the content and our discussions been relevant to your
work here as an RN. Customer satisfaction will be assessed through both the observations of the
Program Lead Trainer as he/she observes the participants including body language and
commentary as well as from the Immediate Evaluations following the initial training and
following the annual training. The components to measure reactions to the program are
summarized in Table 17.
Table 17
Components to Measure Reactions to the Program.
Method(s) or Tool(s) Timing
Engagement
Attendance records At beginning of initial trainings and at annual
trainings

Asking meaningful questions During all trainings (Observations by Program
Lead Trainer and Immediate Evaluations)

Participation of RNs during group discussions
during trainings
During all trainings (Observations by Program
Lead Trainer)
Relevance
Pulse check via survey and/or group
discussions

During all trainings before or after breaks
Anonymous surveys After initial trainings and after annual trainings
Customer Satisfaction
Dedicated observer who gauges student
commentary and body language

During all trainings
Anonymous surveys After initial trainings and after annual trainings

116
Evaluation Tools
Prior to attending initial program. The administration of a pretest will occur 3 to 4
weeks before the RN attends the program and will assess Levels 1 and 2 (Appendix D).
Immediately following the program implementation. The administration of an
Immediate Evaluation (Appendix E) will occur at the conclusion of the program and will include
evaluations for Level 1 and level 2.
Delayed for a period after the program implementation. A Delayed Evaluation
(Appendix F) will be administered 6 months following the program and will include evaluations
for Levels 1,2,3 and 4.
Data Analysis and Reporting
Concurrently and ongoing. The hospital will establish a formal reporting process if one
does not already exist for staff members to report incidents of aggression or physical violence by
patients or visitors (sample shown in Figure V). A Dashboard will be created that will include
number of incidents of aggression and physical violence toward hospital staff from Incident
Reports and other mechanisms (i.e., Security/ Public Safety date, Employee Occupational Health
Services (EOHS) data, etc.) (sample shown in Figure W). A formal meeting will be scheduled
and will include representatives from Security/ Public Safety, Patient Care Services (includes
Nursing), Risk Management, Patient Safety and Employee Occupational Health Services. This
group will meet at least monthly to review each Incident Report to identify trends and/or
opportunities for improvement. Included within the monthly meetings will be reports of injuries
and/or lost work time because of a physical injury or emotional stress. Quarterly the data from
this dashboard will be reported out as total numbers of reported events and lessons learned
117
and/or interventions or actions taken by the hospital to share with all hospital employees (Figure
W and Figure X).
Report of Aggression or Physical Violence
Date of report
Date of event
Time of event
Location of event
Type of event
Narrative Description of Event
Patient: Y,N, or N/A If yes, Medical Record #
Visitor(s): Y, N, or N/A If yes, Names if known:
Staff Member(s) Involved Name(s) and Role(s):
Witness(es) Name(s) and extension
Injury to Patient: Y or N If yes, description
Injury to Staff: Y or N If yes, name(s) and description of injury.
If yes, seen by EOHS?
Additional clinical factors: (select all that apply)- Delirious, altered mental status/ disease process, under the
influence of drugs/ alcohol, withdrawing from drugs/ alcohol, other (describe)
Additional miscellaneous factors: (select all that apply)- long wait for appointment, received bad news about self/ loved
one, other (describe)
Response (select all that apply)- De-escalation strategies:(describe), Security/ Public Safety called,
Other staff in unit called to help, Medical Intervention per MD, other: ______
Name of staff member completing
report:
Name and extension:
Figure V: Sample of Incident Reporting Tool
118

Figure W: Sample Dashboard

(Sample Update in a Hospital Newsletter)
Workplace Violence Prevention Committee Update:

● Aggression and Physical Violence Dashboard 2016
○ We are continuing to collect data, anticipate an initial increase in
most areas as staff are more likely to report incidents
○ After next quarter we will look to see if there are any trends and
brainstorm at staff meetings ways we may intervene

● Management of Aggression and Physical Violence Program
○ So far 256 RNs have attended the program (out of 2,000 RNs)
○ Upcoming Sessions: First Monday of each month, register
online

● Employee Injuries
○ 4 during the past quarter and 3 have been able to return to work

Interested in being a Unit Based Champion? Speak with your Manager for more information!
Figure X: Sample Update for a Hospital Newsletter
119
Summary
The problem of violence experienced by RNs working in hospitals is important to solve
for a variety of reasons. There can be significant physical and psychological harm experienced
by these healthcare workers who experience violence, including physical injury, disability,
psychological trauma or death (National Institute for Occupational Safety and Health (NIOSH),
2002). Violence toward health care workers may result in lost work time, decreased employee
morale and increased employee turnover (NIOSH, 2002; O’Brien, Tariq, Ashraph and Howe,
2014). The stakeholder group of focus was RNs working in hospitals in Massachusetts, however
these recommendations for practice may also be relevant for other stakeholders including
physicians, physical therapists, and nursing assistants.
To achieve the desired outcomes of preventing physical and psychological harm to RNs
while keeping patients safe, it is necessary for knowledge influences, motivational influences and
organizational influences be included in the recommendations for practice beginning with the
four levels of evaluation of training as described in the New World Kirkpatrick Model (2016).
Reflecting upon the Conceptual Framework of this problem of practice supported by results of
the study, the New World Kirkpatrick Model (2016) was used to plan an intervention beginning
with Level 4 and identifying how to measure results and leading indicators to determine if the
desired outcome is achieved.
Circling back continuously to the Conceptual Framework (Figure A), Critical Behaviors
were identified that would be necessary to achieve the desired outcomes including knowledge,
motivational and organizational influences. Level 3 translated into suggested interventions for
both the content of a training program for RNs about managing aggression and physical violence
and expectations for hospitals to provide the necessary resources to support the training, create a
120
mechanism for reporting incidents of aggression or physical violence, create a dashboard to
measure the amount and types of incidents, establish a committee to review events and identify
opportunities for improvement.
Level 2 Evaluation in the New World Kirkpatrick Model (2016) described methods to
assess the components of learning, specifically as it relates to knowledge and motivational
influences while Level 1 measured the reaction to the training program including engagement
and customer satisfaction. By knowing and articulating the desired outcomes, there was
alignment of the recommendations and planned interventions throughout this process. Using the
New World Kirkpatrick Model (2016) along with Clarke and Estes (2011) KMO Conceptual
Framework a comprehensive analysis, plan for the development and implementation and
ongoing evaluation was created to respond to the problem of aggression or physical violence by
patients or visitors towards RNs in hospitals. Ultimately it is hoped that by investing resources
into training RNs to understand, recognize and respond to aggression and physical violence by
patients or visitors will result in a decrease in employee injuries, lost work time, and/or
psychological trauma of RNs. In addition, it is hoped that RNs’ confidence in their ability to
respond to an aggressive or physically violent patient or visitor will increase through all of these
interventions.

121
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136
Appendix A
Survey Items
For the purposes of this study, we will define workplace violence as aggression and/or
physical violence.:

Aggression will include verbal communication that is perceived as hostile, angry,
threatening or demeaning and threatening behavior such as the act of punching a wall.

Physical violence will include the actual act of / or attempt to hit, punch, slap, push, kick,
spit upon, scratch, bite, assault with a weapon, sexually assault, squeeze tightly, throw an
object and/or strangle another individual.
1. Please select your primary work setting? (dropdown)
a. Skilled Nursing Facility
b. Rehabilitation Facility
c. Hospital/ Medical Center
d. School (K-12 or University)
e. Community (Home Health or Public Health
f. Other:
i. If respondent did not answer “c”, then the survey will end

2. Are you a Registered Nurse in Massachusetts?
a. No
b. Yes
ii. If no, then the survey will end

3. What is your role in your organization? (dropdown)
a. RN providing direct patient care
b. RN in a supervisory or administrative role
c. RN in another nursing leadership role
d. Other __________

4. What gender do you identify with? (dropdown)
a. Male b. Female c. Additional gender category (or other): d. Decline to answer
5. How many years have you worked as an RN? (dropdown)

137
Appendix A (continued)
6. What degrees have you obtained? (select all that apply)
a. Bachelor’s in Nursing
b. Bachelor’s other
c. Associates in Nursing
d. Associates other
e. Diploma in Nursing
f. Master’s in Nursing
i. Master’s other
g. PhD Nursing or DNP
i. Doctorate Other
h. Other: _____________

7. What is your age? (dropdown)
8. Are you of Hispanic, Latino, or Spanish origin? (select all that apply)
a. No
b. Yes, Mexican, Mexican American, Chicano
c. Yes, Puerto Rican
d. Yes, Cuban
e. Yes, another Hispanic, Latino or Spanish origin: __________
f.
9. What is your race? (please check all that apply)
a. White
b. Black or African American
c. American Indian or Alaska Native
d. Chinese
e. Filipino
f. Asian Indian
g. Other Asian: ________
h. Vietnamese
i. Korean
j. Japanese
k. Native Hawaiian
l. Samoan
m. Chamorro
n. Other Pacific Islander: _________
o. Some other race: ___________

138
Appendix A (continued)

10. In what area of Massachusetts is your primary work setting located? (dropdown)
a. Boston
b. Greater Boston area
c. South Shore
d. North Shore
e. Central Massachusetts
f. Western Massachusetts
g. Other: _______
11. \On average, how often do you experience acts of aggression or physical violence
towards you by patients or visitors in your primary workplace? (dropdown)
a. Never
b. A couple of times a year
c. Once every three months
d. Once a month
e. Once a week
f. Every day
g. Other

12. On average, how often do you report incidents of aggression or physical violence by
patients or visitors toward you in your primary workplace? (dropdown)
a. Never
b. Rarely
c. Some of the time
d. Most of the time
e. Always

13. How would you help a novice nurse manage a situation when a patient or visitor becomes
aggressive or physically violent? (open ended)

14. How do you personally cope following a situation when a patient or visitor was
aggressive or physically violent? (open ended)

15. How effective do you believe that your primary workplace’s approach to addressing
issues of aggression and physical violence from patients or visitors in the workplace?
(open ended)

16. My organization takes incidents of aggression or physical violence by patients or visitors
seriously
a. Strongly Disagree b. Disagree c. Agree d. Strongly Agree

17. I am confident in my ability to de-escalate an aggressive patient or visitor
Range from 1 (strongly disagree) to 10 (strongly agree)

139
Appendix A (continued)
18. I am confident in my ability to protect myself if a patient or visitor becomes physically
violent towards me
Range from 1 (strongly disagree) to 10 (strongly agree)

19. My supervisor takes appropriate action when a patient or visitor is aggressive or
physically violent towards me
a. Strongly Disagree b. Disagree c. Agree d. Strongly Agree

20. When a patients or visitor becomes aggressive or physically violent towards me I
feel:(open ended)
21. My work area has a “panic button” or some type of way to silently alert security about a
safety threat in my area
a. Yes b. No c. I don’t know

22. My organization has a formal Hospital Safety Report or Incident Reporting process to
report when patients or visitors are aggressive or physically violent
a. Yes b. No c. I don’t know

23. I am encouraged to complete Hospital Safety Reports/or some type of Incident Report
whenever a patient is aggressive or physically violent toward me
a. Strongly Disagree b. Disagree c. Agree d. Strongly Agree

24. I have been trained by my organization about the following topics:
(select all that apply)
a. De-escalation techniques
b. Responding to a verbal threat
c. Strategies to protect myself from physical violence
d. When to call Security/ Public Safety
e. How to report when a patient is physically violent toward you
f. Other: _______________
g. Not Applicable
25. Do you have any other thoughts that you would like to share about the issue of aggression
and physical violence in hospitals? (open-ended)
Thank you for your time and participation!

140
Appendix B
University of Southern California
Rossier School of Education
Waite Phillips Hall
3470 Trousdale Parkway
Los Angeles, CA 90089

INFORMATION/FACTS SHEET FOR EXEMPT NON-MEDICAL RESEARCH

VIOLENCE EXPERIENCED BY REGISTERED NURSES WORKING IN HOSPITALS:
AN EVALUATION STUDY

You are invited to participate in a research study. Research studies include only people who
voluntarily choose to take part. This document explains information about this study. You should
email the Principal Investigator if you have questions about anything that is unclear to you.

PURPOSE OF THE STUDY
This study is conducted by a graduate student from the University of Southern California as part
of the dissertation process. Your participation would help to gather data about your experience as
the recipient of aggression and/or physical violence as an RN working in a hospital. The purpose
of the study is to evaluate the knowledge, motivation and organizational influences in regards to
aggression and physical violence toward RNs in Massachusetts hospitals and the degree to which
Massachusetts Hospitals are successfully implementing violence prevention programs.

PARTICIPANT INVOLVEMENT
If you agree to take part in this study, you will be asked to complete an online survey which is
expected to take about 15 minutes. You do not have to answer any questions you don’t want to,
click “NEXT” in the survey to move to the next question. Questions are both open ended and
multiple-choice. There are no direct benefits to you for participating in the study. The potential
risks and discomforts that are anticipated are minimal as there is a small risk that some of the
questions may conjure unpleasant feelings or memories. Your participation will remain
confidential and information that you share will not contain any identifiers to you.

PAYMENT/COMPENSATION FOR PARTICIPATION
At the completion of the survey, you will have the opportunity to enter into a drawing for a
chance to win one of five Starbucks ® gift certificates for $10. The information you enter into
the drawing is separate from the survey that you completed. The winners will be notified via
email.

141
APPENDIX B (continued)

ALTERNATIVES TO PARTICIPATION
Your participation is voluntary and the alternative is not to participate in this study.

CONFIDENTIALITY
Your participation will remain confidential and information that you share will not contain any
identifiers to you. The data will be stored on a password protected computer in the researcher’s
office for three years after the study has been completed and then destroyed.
The members of the research team and the University of Southern California’s Human Subjects
Protection Program (HSPP) may access the data. The HSPP reviews and monitors research
studies to protect the rights and welfare of research subjects. When the results of the research are
published or discussed in conferences, no identifiable information will be used.

INVESTIGATOR CONTACT INFORMATION
Principal Investigator: Susan Holland at sholland@usc.edu
Faculty Advisor: Kimberly Hirabayashi at hirabaya@usc.edu

IRB CONTACT INFORMATION
University Park Institutional Review Board (UPIRB), 3720 South Flower Street #301, Los
Angeles, CA 90089-0702, (213) 821-5272 or upirb@usc.edu

142
Appendix C
Recruitment Letter
Hello!
I am a graduate student at the University of Southern California and am seeking
volunteers as part of my dissertation process. I invite you to participate in gathering data about
the knowledge, motivation and organizational influences in regards to aggression and physical
violence toward RNs in Massachusetts hospitals. Your participation consists of completing an
online survey. Questions are both open ended and multiple choice. There are no direct benefits
to you for participating in the study. The potential risks and discomforts that are anticipated are
minimal as there is a small risk that some of the questions may conjure unpleasant feelings or
memories.
Your participation is voluntary and the alternative is not to participate. If you decide to
participate, you will be given a website address and asked to complete an anonymous online
survey. Completion of the online survey should take about 15 minutes.
At the completion of the survey, you will have the opportunity to enter into a drawing for
a chance to win one of 10 Starbuck’s gift certificates for $10. The information you enter into the
drawing is separate from the survey that you completed.

Sincerely,

Susan Holland, RN, MS, Student
Rossier School of Education at the University of Southern California

143
Appendix D
Pre-test Before Program
For the purposes of this questionnaire, we will define workplace violence as aggression
and/or physical violence.:
Aggression will include verbal communication that is perceived as hostile, angry,
threatening or demeaning and threatening behavior such as the act of punching a wall.
Physical violence will include the actual act of / or attempt to hit, punch, slap, push, kick,
spit upon, scratch, bite, assault with a weapon, sexually assault, squeeze tightly, throw an
object and/or strangle another individual.
1. On average, how often do you experience acts of aggression or physical violence
towards you by patients or visitors in your primary workplace? (dropdown)
a. Never
b. A couple of times a year
c. Once every three months
d. Once a month
e. 2-3 times a month
f. Once a week
g. 2-3 times a week
h. Every day
i. Other

2. On average, how often do you report incidents of aggression or physical violence
by patients or visitors toward you in your primary workplace? (dropdown)
a. Never
b. Rarely
c. Some of the time
d. Most of the time
e. Always
f. Other

3. List 2 supports that exist in the hospital that you could call or seek out for
immediate help to assist you if you are confronted by an aggressive and/or violent patient
or visitor: (L2)
a. ________________ b. __________________

144
Appendix D (continued)
4. List 2 supports that exist in the hospital that are available to help emotionally
support you in your work: (L2)
a. ________________ b. __________________

5. I am confident in my ability to de-escalate an aggressive patient or visitor. (L2)
Range from 1 (strongly disagree) to 10 (strongly agree)

6. I am confident in my ability to protect myself if a patient or visitor becomes
physically violent towards me (L2)
Range from 1 (strongly disagree) to 10 (strongly agree)

7. I have been trained by my organization about the following topics: (L1)
(select all that apply)
a. De-escalation techniques
b. Responding to a verbal threat
c. Strategies to protect myself from physical violence
d. When to call Security/ Public Safety
e. How to report when a patient is physically violent toward you
f. Other: _______________
g. No training has been provided in these topics by my organization

Thank you for your time and participation!

145
Appendix E
Immediate Evaluation Form After Program (Levels 1 and 2)
For the purposes of this questionnaire, we will define workplace violence as aggression
and/or physical violence.:
Aggression will include verbal communication that is perceived as hostile, angry,
threatening or demeaning and threatening behavior such as the act of punching a wall.
Physical violence will include the actual act of / or attempt to hit, punch, slap, push, kick,
spit upon, scratch, bite, assault with a weapon, sexually assault, squeeze tightly, throw an
object and/or strangle another individual.

1. I understood the learning objectives during this program. (L1)
a. Strongly Disagree b. Disagree c. Agree d. Strongly Agree

2. I found that the course content of this program relevant to my work. (L1)
a. Strongly Disagree b. Disagree c. Agree d. Strongly Agree

3. My learning was enhanced by the knowledge of the Program Facilitator. (L1)
a. Strongly Disagree b. Disagree c. Agree d. Strongly Agree

4. I was comfortable with the pace of the Program. (L1)
a. Strongly Disagree b. Disagree c. Agree d. Strongly Agree

5. The facility was conducive to my learning. (L1)
a. Strongly Disagree b. Disagree c. Agree d. Strongly Agree

6. I am confident in my ability to de-escalate an aggressive patient or visitor (L2)
Range from 1 (strongly disagree) to 10 (strongly agree)

7. I am confident in my ability to protect myself if a patient or visitor becomes
physically violent towards me (L2)
Range from 1 (strongly disagree) to 10 (strongly agree)

8. List 2 supports that exist in the hospital that you could call or seek out for
immediate help to assist you if you are confronted by an aggressive and/or violent patient
or visitor: (L2)
a. ________________ b. __________________

9. List 2 supports that exist in the hospital that are available to help emotionally
support you in your work: (L2)

a. ________________ b. __________________
10. Do you have any other thoughts you would like to share about this program? (open
ended)

Thank you for your time and participation!
146
Appendix F
Delayed Evaluation – 6 months after Program (Levels 1, 2, 3 and 4)
For the purposes of this questionnaire, we will define workplace violence as aggression
and/or physical violence.:
Aggression will include verbal communication that is perceived as hostile, angry,
threatening or demeaning and threatening behavior such as the act of punching a wall.
Physical violence will include the actual act of / or attempt to hit, punch, slap, push, kick,
spit upon, scratch, bite, assault with a weapon, sexually assault, squeeze tightly, throw an
object and/or strangle another individual.

1. On average, how often do you experience acts of aggression or physical violence
towards you by patients or visitors in your primary workplace? (dropdown) (L1, L4)
a. Never
b. A couple of times a year
c. Once every three months
d. Once a month
e. 2-3 times a month
f. Once a week
g. 2-3 times a week
h. Every day
i. Other

2. On average, how often do you report incidents of aggression or physical violence
by patients or visitors toward you in your primary workplace? (dropdown) (L1, L4)
a. Never
b. Rarely
c. Some of the time
d. Most of the time
e. Always
f. Other

3. What supports in the hospital have you used to help you manage a patient or
visitor who was aggressive or physically violent? (open ended) (L3)

4. What supports have you accessed to help support you emotionally in your work as
a nurse ? (open ended) (L3)

5. I am confident in my ability to de-escalate an aggressive patient or visitor (L2)
Range from 1 (strongly disagree) to 10 (strongly agree)

6. I am confident in my ability to protect myself if a patient or visitor becomes
physically violent towards me (L2)
Range from 1 (strongly disagree) to 10 (strongly agree)
147
Appendix F (continued)

7. I have applied the following during the past 6 months in my practice: (L3)
(select all that apply)
a. De-escalation techniques
b. Strategies to respond to a verbal threat
c. Strategies to protect myself from physical violence
d. Calling Security/ Public Safety for immediate assistance
e. Reporting when a patient was physically violent toward you
f. Reporting when a patient or visitor was aggressive towards you
g. Other: _____________ (open ended)
h. None of the above

8. Do you have any other thoughts you would like to share? (open-ended)

Thank you for your time and participation!

148
Appendix G
Annual Anonymous Survey of RNs
For the purposes of this questionnaire, we will define workplace violence as aggression
and/or physical violence.:
Aggression will include verbal communication that is perceived as hostile, angry,
threatening or demeaning and threatening behavior such as the act of punching a wall.
Physical violence will include the actual act of / or attempt to hit, punch, slap, push, kick,
spit upon, scratch, bite, assault with a weapon, sexually assault, squeeze tightly, throw an
object and/or strangle another individual.

1. On average, how often do you experience acts of aggression or physical violence
towards you by patients or visitors in your primary workplace? (dropdown) (L1, L4)
a. Never
b. A couple of times a year
c. Once every three months
d. Once a month
e. 2-3 times a month
f. Once a week
g. 2-3 times a week
h. Every day
i. Other

2. On average, how often do you report incidents of aggression or physical violence
by patients or visitors toward you in your primary workplace? (dropdown) (L1, L4)
a. Never
b. Rarely
c. Some of the time
d. Most of the time
e. Always
f. Other

3. I am confident in my ability to de-escalate an aggressive patient or visitor (L2)
Range from 1 (strongly disagree) to 10 (strongly agree)

4. I am confident in my ability to protect myself if a patient or visitor becomes
physically violent towards me (L2)
Range from 1 (strongly disagree) to 10 (strongly agree)

5. Do you have any other thoughts you would like to share? (open ended)

Thank you for your time and participation!

149
Appendix H
Sample Program Outline and Sample Agenda

Day of Program

8:00am Welcome
8:15am Introduction
a. Aggressive Behaviors
b. Physical Violence
c. Hospital’s Philosophy
d. Specific Hospital Data
8:45am Etiology
e. Hospital Environment
f. Emotions and Coping
g. Society
9:45am Break
10:00am Recognition
h. Patient/ Family History
i. Agitation and Frustration
10:30am De-escalation Strategies
j. Useful Skill in General
k. What to Address Immediately
l. What Not to Say
m. Listening
n. Repeating or Clarifying Problem
o. Respond
p. Activity
i. Demonstrations/ Observations
ii. Role Play
iii. Group Discussion
12:00pm Lunch
12:45pm Review of Morning
1:00pm Supports Available (hospital specific)
1:30pm Keeping Yourself and Others Safe
q. Environment
r. When a Patient is Sectioned and Attempts to Leave
s. Positioning of Self in Tense Situations
t. Strategies to Care for Patient
u. Defense Strategies for Physical Violence
2:30pm Break
2:45pm Keeping Yourself and Others Safe (continued)
v. Activity
i. Demonstrations/ Observations
ii. Role Play
iii. Group Discussion
150
Appendix H (continued)

3:30pm Taking Care of Yourself
4:00pm Final Thoughts
4:15pm Completion of Immediate Evaluation (Appendix E)

6 Months After Program
Completion of Delayed Evaluation (Appendix F)

1 Year After Program and then Annually
Completion of Annual RN Survey (Appendix G)

Abstract (if available)

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Asset Metadata

Creator Holland, Susan M. (author)

Core Title Violence experienced by registered nurses working in hospitals: an evaluation study

School Rossier School of Education

Degree Doctor of Education

Degree Program Organizational Change and Leadership (On Line)

Publication Date 09/29/2017

Defense Date 09/07/2017

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag aggression,anxiety,confidence,Emotions,Fear,gap analysis,Hospital,KMO,metacognitive,Motivation,nurse,OAI-PMH Harvest,organizational influences,Patient,physical violence,registered nurse,reporting,RN,self-efficacy,Violence,visitor,workplace violence

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Hirabayashi, Kimberly (committee chair), Seli, Helena (committee member), Stevens, Jennifer P. (committee member)

Creator Email sholland@usc.edu,solisortis@aol.com

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c40-440554

Unique identifier UC11264290

Identifier etd-HollandSus-5800.pdf (filename),usctheses-c40-440554 (legacy record id)

Legacy Identifier etd-HollandSus-5800.pdf

Dmrecord 440554

Document Type Dissertation

Rights Holland, Susan M.

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the a...

Repository Name University of Southern California Digital Library

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