Demographic Study
Interviews were conducted between February 2014 and March 2014. Thematic saturation was reached with 13 participants. The participants include medical officers (n = 4; 31%), nurses (n = 4, 31%), assistant medical officers (n = 4; 31%) and hospital attendant (n = 1; 7%). Participants had a varying length of experience in working at ETD, ranging from less than a year to 13 years. However, all participants had experience working under government health service for at least two years.
Table 1
Participants
|
Age
|
Position
|
Years of service
in ED
|
Years of Service in
Ministry of Health
|
P1
|
38
|
Nurse
|
7
|
15
|
P2
|
28
|
Nurse
|
5
|
5
|
P3
|
36
|
AMO
|
6
|
11
|
P4
|
33
|
MO
|
4
|
9
|
P5
|
29
|
MO
|
2
|
4.5
|
P6
|
24
|
Nurse
|
less than 1 year
|
2
|
P7
|
28
|
Nurse
|
5
|
5
|
P8
|
38
|
AMO
|
13
|
13
|
P9
|
33
|
MO
|
4
|
8
|
P10
|
40
|
MO
|
6
|
9
|
P11
|
28
|
AMO
|
5
|
5
|
P12
|
34
|
PPK
|
2
|
3
|
P13
|
34
|
AMO
|
8
|
8
|
Thematic Analysis Matrix (TAM) (10)
This section will explain about thematic analysis process. Thematic analysis is a systematic method used to analyze data in qualitative research. The steps involved are 1) familiarising with data, 2)generating preliminary codes, 3) search for themes, 4) review themes, 5) define themes, and 6) write-up(11) The thematic analysis matrix for this study is presented in Table 2.
Table 2
Codings
|
Categories
|
Final Themes
|
Inductive codes
|
Vigilant of verbal and non-verbal cues
|
Mental, emotional
and behavioural preparedness
|
Coping during pre-crisis
-aggressor showed potential violence behaviour
-Response aimed at preventing a violent incidence
|
Coping response change to match the level of aggression displayed by the perpetrator.
Coping strategy to violence starts even before the incident of violence occur
Self-restraint is frequently use as a coping response
Coping with workplace violence does not stop after a crisis ended
|
Adopt appropriate verbal and behavioural response
|
Reducing mismatch between expectation and realities
-explain what to be expected
-announcement to explain the situation
-aware of the limitation
|
Mental planning for possible violence event
|
Disengagement for fear of losing control
|
Self-Restraint
|
Coping during crisis
-Aggressor had become hostile and displayed verbal or physical violence.
-Participant coped by controlling the situation from escalating further
|
Self-restraint and not responding to a hostile attitude
|
Present calm and professional attitude
|
Allow perpetrator to vent and find the root cause
- get the perpetrator to explain the source of their frustration
-let patient ventilate, ask the patient the reason for their action
-let perpetrator cool off by leaving them alone temporarily, then come to clarify
|
Constructive confrontation
|
Clarify situation by explaining, educating or apologizing
|
Showing empathy and rapport
-make the patient feel they are being prioritized
-offer help to solve the problem, facilitate
-put the patient in different environment/zone
-show empathy and build rapport
|
Draw the line
-Standing against the perpetrator
-Let perpetrator now that they have proof of their violence act
|
Disengaged to seek help and for safety reason
|
Seeking instrumental support
|
Get help for an extra hand in handling aggressive visitor or patients
|
Get help from superior to become the mediator
|
Find a place to cry or calm down
|
Seeking emotional support
|
Coping during post-crisis
-after a violent incident had occurred
-response aimed at addressing the emotional impact of violence and learning from their experience to improve in the way they are managing violence
|
Deviate attention by engaging in small talk with friends or making jokes
|
Venting problem to others
|
Temporarily avoid the place where violence just occur
|
Disengagement
|
Reduce unnecessary contact with patients and relative
|
Avoid from getting involved in violence incident
|
Taking a short time away from work
|
Get advice from a more experienced colleague and engage in post violence discussion
|
Adaptation
|
Conduct debriefing session with subordinate
|
Looking at the situation from another perspective
|
Twenty-four initial codings were derived from participants' quotations, and seven categories were identified from the initial codings. Subsequently, three themes emerged from the data. The themes and categories are
-
Coping during pre-crisis: mental and behavioural preparedness.
-
Coping during a crisis: self-restraint, constructive confrontation, seeking instrumental support.
-
Coping during post-crisis: seeking emotional support, avoidance and positive reinterpretation
Participants cope with workplace violence through three phases. In the pre-crisis phase, the aggressor showed potential violent behaviour, and participants' responses during this phase were aimed at preventing a violent incidence. During the crisis phase, the aggressor had become hostile and displayed verbal or physical violence. Participants coped by controlling the situation from escalating further. In the post-crisis phase, participant responses were aimed at addressing the emotional impact of violence and learning from their experience to improve in the way they were managing violence.
PRE-CRISIS
Mental and behavioural preparedness for a possible violent event
Most participants are conscious that, despite their prior experience, violence may occur at any time. One aspect of being prepared is to consider both verbal and non-verbal hints. They learn from patients or relatives by body language, facial expression and the tone of voice use. Healthcare Assistant 1 reported "When I saw the face of the patient's family planting anger, I will get prepared. In normal circumstances, I will just keep quiet. I will communicate inappropriate tone, as to how I should communicate with them." Ok, I am going to send this patient to the ward, would you like to follow me?" Sometimes when they are in anger, even our tone of voice can initiate a fight."
A participant says that they would be careful of the vocabulary and tone of voice they use. Some will limit communication between them while showing sympathy and building a relationship is among the behaviour of some of the participants. "I learnt from non-verbal cues such as body language of the patients, relatives and the staffs. For example, when dealing with relatives who brought ill-children, sometimes it helps for doctors to show empathy and build rapport, as this could prevent or reduce potentials offensive behaviour from them."
Some participants are taking prudent behaviour. During all times, they are aware of their acts and words, fearing that they could trigger an incident of violence. A mismatch between the client's expectations and the care offered is one of the triggers of an aggressive event. The staff say that they need to be discreet in describing the patient's need to bridge the gap between expectation and fact. This is so that they can reach a consensus about the most effective care for patients. "When they anticipate differently, or they think that they are very well-read, and they expect something to be done, but you do not do it, that is when they will create a problem. Another part of it is actually how do we handle them. Sometimes you must be very nice, and sometimes you must be very discreet. They have their expectations before they come to the hospital." (Medical Officer 2)
DURING CRISIS
Self-restraint
Participants restricted themselves from being impulsive or responding in an equally hostile manner. Some will not respond to the violent remark and remain silent while others disengaged themselves from the scene of the incident for fear of losing control. Assistant Medical Officer 4 reported "There were those who kept on scolding. But I did not respond and just listen to him. There is nothing I can do since he is already angry. I kept on listening and did not retaliate back. After a while, he will stop on his own".
Participants reported that they continue to act courteously and professionally despite being subjected to violence. "If they give racist or indecent remark, I'll just smile. I can only do that much. So fa,r when I do that, it worked. Those who are angry might become calmer, and it helps to prevent from initiating a fight. At least we will be able to avoid a bigger fight, causing property damage, or physical violence. Try to avoid it. So far, this method is effective". (Assistant Medical Officer 1)
Understanding the state of mind of the aggressor helps some participants to moderate their emotional reactions and prevent them from acting irrationally. A participant indicated that there was an incident in which he did not react at all to the aggressor despite being exposed to physical aggression because he recognized that the aggressor was not in a good state of mind and could make the situation worse by reciprocating the behaviour. "Suddenly, the patient came, kicking the door. It was a glass door, and it broke. He came in. He asked, "Who has the highest authority here?". Incidentally, I was in charge of Red Zone at that time, so the others pointed at me. He grabbed me, push me against the wall and he asked, "are you the police? Are you the police?" He was drunk, and he was half-conscious, so I just stayed silent."
(Medical Officer 4)
Constructive confrontation with the perpetrator to resolve the conflict
Confrontation includes elements in which the participant will find the root of the cause by allowing the offender to ventilate, explore the depth of their understanding and explain the reason for their frustration.
Suppose they can identify the root of the issue. In that case, the participant will clarify the situation by informing the patient on the essence of the disease and its course of care, explaining the general operation and protocol of the emergency department, or clearing up a misunderstanding of the situation. "For example, if they are shouting at me, assess their understanding. What is it that you understand? What is it that you want from me? What is it that you are not happy with? So, I'll tackle one by one. Usually, it works. Because most of the time, people are just anxious, they easily misinterpret your words and your tones as being ignorance, arrogance. That makes them think that we don't empath them and we don't understand what is going on with them".
Nurse 3 explained the process of apologizing. Initially, the victim should be disengaged to allow the aggressor time to cool down, followed by an explanation of the situation and apologies regardless of who is wrong. "Reply politely to them. During the confrontation, let them be. After some time, return to them and apologize. Just tell them you are sorry, it's not wrong to do that. I have done this before. Return apologize to them for whatever you have done and explain to them the reason for it, for example, if you were tired".
However, when the above strategies are not successful, or victim feels that the aggression has become overboard, some participants take a stand to draw the line, warn the perpetrator that they have collected evidence of their actions and will submit a report to the authority.
Seeking instrumental support
When a situation has become out of control, getting help from a senior colleague or a higher authority person helps to resolve the problem because they can act as a third person. The third person has typically more experience dealing with violence and can act as a mediator between the participant and the aggressor. Assistant Medical Officer 4 reported that this action will help to calm both parties and will be able to resolve the issue more professionally. "I observed a disagreement between my colleague and a patient's relative. The conflict eventually became heated and loud. So, the supervisor gathered them in a room for a discussion between my friend and the relative of the patient. Both my friend and the relative was furious at that time. The supervisor asked each of them to explain and then discuss the situation in a calm manner. I saw that in the end, they were shaking hands and laughing with each other. So, I think it helps. Especially when the discussion is appropriately done in a room between the parties involved, it appears more professional.
Another element of seeking support is to get the involvement of another colleague to attend to the patient when the participant needs time away from the incidence scene. Participant reports that they will get help from others when they need extra help in treating patients who are restless and uncooperative. Patients of this type are typically psychiatric patients or patients who are semi-conscious due to illness. Another reason to seek the support of a colleague is when the situation has become out of control, and the aggressor has the potential to become or has shown physical violence. Participants must separate themselves from the aggressor for their safety when seeking assistance from another colleague. Some ask the security officer or auxiliary police for help "If I the person become really angry, I will distance myself from them for safety reason. Then I will get help from my supervisor and security guard so they can take over". (Assistant Medical Officer 1)
POST - CRISIS
Seeking emotional support
Respondents report several elements related to seeking emotional support. There are others who are making jokes and talking to a friend to deviate their attention from the issue at hand. Others seek comfort by weeping or venting their complaints to relatives, a senior colleague and a spouse. Venting is the most common coping technique to be used. Most of those who vent their problems to a colleague prefer to do so with a colleague from a similar line of work. They do that because they feel that their colleague have a better understanding of the situation faced by the respondents. "Receiving scolding and offensive words is a common situation. I am already immune to it. It does not give any lasting effect anymore. Normally when it happens, you talk to your friends, just sharing among us, because they understand the situation. Same goes to my colleague. They will come to me saying "I am stress! I am stress! I want to talk" I'll let them talk. That's what we usually do". (Nurse 4)
The most frequent use of seeking emotional support is among assistant medical officers and nurses. Participants agree that the violent incident culminated in this help to alleviate their rage and frustration. There is a feeling that the occurrence of violence is going to recur, and this is a regular event. Thus, respondents need to vent the incident to help them cope emotionally and psychologically so that they are ready to face subsequent encounters.
A few participants use incidence report to ease their worries. However, most don't record all violence incidence. They will continue to report incidents when the event is significant (e.g. physical violence) or when they think there will be sequelae from the violent incident, as evidence to protect themselves. "I make incident reporting for peace of mind. But, I don't regularly make incident reporting, because most of the time, the conflict is minor. It resolves with proper explanation. However, even though it is verbal, I'll report on the major conflict. It helps emotionally and mentally because it helps people who think they know your position at the time as to why it happened, what happened and the measures I took". (Assistant Medical Officer 3)
Disengagement
Some participants will take a short time out after an incident of aggression and will find a place to calm down. They will temporarily avoid the site where the incidence of violence simply occurs or prevent from meeting the aggressor. Others minimize excessive contact with patient and relative. "For me, when I am feeling down, I will take a short break to relax. I will just sit there without doing anything or talk to my colleagues. 10 to 20 minutes is enough, and after that, I am good. I might temporarily avoid the ward where a violent incident just took place. I will go to other wards first before I send the patient to that ward. I do this is so that my emotion is not affected". (Healthcare Assistant 1)
Participants benefit from taking time off work. They either stay at home to rest and sleep, take part in outdoor activities, engage with friends or go shopping. They feel that after a brief time out of work, they are more motivated "I am happy if I can get a leave. After a leave, I fill more spirited when I return to work." (Medical Officer 3)
Adaptation
Adapting to violence requires participants to deal with its emotional impact and learn the skill to manage violence. Some participants look back into the incident and re-analyze it. Some are actively seeking advice from senior colleagues or conducting a post-violence discussion with them to re-analyze their actions and improve their skills in dealing with such cases. "I learn how to handle a violent event informally. There is no formal training. So, the way I thought myself was to have a post violent discussion. I will meet with senior supervisors for advice. They will give me input on how I can improve when face with a violent event in the future". (Medical Officer 1)
Some supervisors conduct a short debriefing session after a violent incident to help the staff ventilate and re-analyze the incident. A managerial post participant reported that he would encourage victims to look from a religious perspective to help them cope with the emotional impact of violence. Looking at the situation from the viewpoint of the patient is one approach often used by the participants. They reassess the conduct of the individual and seek to understand the explanation for their actions. Others can let go of their rage and resentment by recognizing the actions of the victim, "Initially, I felt angry at him. Why he kicked me? All I wanted was to help him. Then, when I start to think back, he was like that because he was sick, and I wanted to help him. I did not expect it to happen. When faced with a patient like that, I should be prepared to save myself from danger. The patient was already irritable and half-conscious". (Nurse 2)
Experiencing repeated exposure to violence has made the participants understand that they will have to face them daily and that this has become part of their work. They are desensitized to the emotional effect of violence and have made them more adaptable to handling the situation. A participant reported: "This is not the first time that it happens. I have faced this many time. Based on my experience facing this situation, this is not something major. Since I have experience handling worse situation than this, I feel, that is the reason this violent event does not affect my work on that day. It also does not make me emotionally unstable or interfere with my work process." (Medical Officer 1)