Violence and aggression in the intensive care unit: What is the impact of Australian National Emergency Access Target?

Abstract

Introduction

Violence in healthcare settings is a concern for healthcare professionals and patients. Media reports, and debate within the healthcare profession, and the academic literature infer that workplaces such as intensive care units are becoming exposed to increasing violence. Increases in the incidence of violent behaviour are sometimes attributed to the increased pressure on emergency departments to accelerate the throughput of patients to meet targets. To ensure the wellbeing of patients and staff, there is a need to evaluate the impact of such targets. The aim in this study was to evaluate the incidence and to describe the context in which patients' aggressive and violent behaviours occurred since the introduction of the National Emergency Access Target in a local tertiary Australian intensive care unit.

Methods

A retrospective examination of events triggering violence-related emergency codes from 12 months before the introduction of the National Emergency Access Target up until 12 months after its implementation (2011–2013).

Results

A small increase in the number of Code Grey/Code Black activation was identified after the introduction of the target (before = 18, after = 29). Admissions following drug overdoses, isolated head trauma, and cardiac arrest were the presentations most likely to have been associated with a violence-related emergency call. Female registered nurses, male critical care registered nurses, and clinical nurse specialists were the most at risk of occupational violence. Male nursing staff members were found to be more likely to be involved in incidences of verbal violence (p < 0.003).

Conclusion

Although there was a minimal increase in the overall number of emergencies triggered by violent behaviour, valuable information on the type of occupational violence occurring towards healthcare professionals and patients in this setting was found. We suggest that these findings add further important detail to the existing understanding of the problem of occupational violence. These detailed insights can further inform policy development, professional education, and practice.

Introduction

Occupational violence is a widespread problem in healthcare settings. The introduction of the National Emergency Access Target (NEAT), also known as the ‘4-h rule program’,¹ in Australia, has led to a perception that its implementation is an explanation for an increase of violence in settings such as the intensive care unit (ICU). This perceived increase in occupational violence through anecdotal reports prompted this investigation. We sought to establish whether an ICU had an actual or perceived increased incidence of occupational violence after the NEAT implementation. It had been suggested that increased pressure to admit to the ICU from the emergency department (ED) earlier than previously could be a factor contributing to the perceived increase of occupational violence. This might have been due to time constraints placed on EDs to meet the NEAT with patients previously managed in the ED being transferred to the ICU earlier.²

The implementation of a 4-h target for EDs or Four Hour Rule Program initially started in the United Kingdom in 2000.³ This target originally aimed for 100% of the patients attending the ED to be seen, treated and discharged, admitted to an inpatient facility, or transferred to a more appropriate location, within 4 h of arrival into the ED. The target was later adjusted to 98% to allow for patients to be kept in the ED to be stabilised fully before transfer, in case of clinical instability.³ In Australia, the NEAT was initially trialled in April 2009 in Western Australia and subsequently introduced to the public healthcare system in January 2012. At the study site, the NEAT was introduced in November 2012. Although the NEAT is still a nationwide target, it was renamed Emergency Treatment Performance (ETP) in 2015 in New South Wales.⁴

The implementation of the NEAT was reported to have provided some positive changes such as improved patient throughput, reduced overcrowding in the ED, improved timeliness to ED care, decreased hospital mortality, and improved discharge planning.[5], [6], [7] While there are clear benefits to patients and the ED, some drawbacks in other areas have also been reported. Some of these drawbacks included an increase in delayed discharges from the ICU, resulting in increased length of stay and increased complexity in the planning and arrangement of patient transfers, for example, to wards that may not be equipped or otherwise prepared to provide the specialised and intensive care required.[5], [8]

There is some acknowledgement that occupational violence in the healthcare setting is already a serious issue.[9], [10], [11], [12], [13], [14] The manifestation of violence or aggression is considered to be complex and multifactorial, with contributing factors such as organisational, environmental, and individual components being recognised as influential.[15], [16] Examples of violent behaviours experienced and reported by nurses and midwives in Victoria included being bitten, kicked, punched, pushed, threatened with weapons, and even included some death threats.¹⁷ In rural areas, Alexander⁹ showed that the most frequent form of violence was verbal, followed by threatening behaviour, physical violence, and sexualised behaviour. Gender differences were also reported, with male nurses proportionally more likely to receive higher rates of physical assaults or violent behaviour than female nurses.[18], [19] Underreporting is another aspect surrounding occupational violence that is widely recognised in the healthcare setting.[11], [15], [19], [20], [21] An explanation for underreporting could be the varying definitions of what constitutes occupational violence. Beech¹¹ highlighted that studies investigating workplace violence usually have different meanings and criteria for what is defined as occupational violence. For example, who is involved, what constitutes violence, and where the incident takes place, all have an impact on whether violence is considered to be occupational violence. These varying and perhaps socially or culturally determined definitions make any comparison of the exact rates of occupational violence between countries or organisations challenging. The terms aggression and violence are often used interchangeably. The definition of aggression considered for the study was as defined by the health service: “any incidents in the clinical setting in which staff members are threatened, abused, or assaulted in circumstances arising out of, or in the course of, their employment” (22, p.3). Violence is sometimes defined differently from aggression as it is more likely to have an intent to cause harm than aggression.²³ There is sometimes an overlap between the two and as stated by the World Health Organization (2002): “Defining it is not an exact science but a matter of judgement.”(24, p. 4)

For the purposes of this study, the definition of occupational violence developed by the International Labour Office and the World Health Organization in the healthcare setting has been adopted. Occupational violence is defined as the following:

Incidents where staff are abused, threatened or assaulted in circumstances related to their work, including commuting to and from work, involving an explicit or implicit challenge to their safety, well-being or health (25, p.10).

Perrone[15], [26] highlighted that occupational violence in the healthcare setting remains mostly underresearched. Some research has taken place in the ED and mental health and nursing home settings, and these areas have been shown to have higher rates of violence.²⁷ There is still very little research investigating occupational violence and the impact of the NEAT implementation on the ICU. This lack of evidence means that the impact of new targets and this change to operational and clinical practice has yet to be systematically evaluated in the ICU setting. The lack of research on this change in practice creates the need to assess whether occupational violence was indeed actually increasing or whether the effect of such violence were being felt more intensively due to time constraints placed on the ED by the NEAT implementation or other pressures. Healthcare facilities in Victoria, Australia, and further afield must ensure that the workplace is safe and minimises risk to the health of its employees. In the state of Victoria, these responsibilities are governed by the Occupational Health and Safety Act, 2004 (p.1025). It is important to note that new standards have recently been developed in all Victorian hospitals in response to incidents of violence and aggression.²²

In Australia, emergency codes in healthcare are standardised,²⁸ and there is one emergency code used for aggressive behaviour, Code Black. In Victoria, however, another code was created as a recommendation from the Inquiry into Violence and Security Arrangements in Victorian Hospitals¹⁹ in an attempt to standardise responses to violence further. A Code Grey is triggered by an actual in-hospital aggressive behaviour, while a Code Black is triggered when a weapon is also present or there is a serious threat to personal safety. The definition adopted for this study is slightly different in that a Code Grey was defined as any incident where a person threatens injury to others or themselves.

This study was designed to investigate whether anecdotal concerns that patients with presenting conditions that might precipitate challenging behaviours were being transferred to the ICU earlier owing to the constraints placed by the NEAT on the ED.

The aims in this study were to (i) determine the incidence of aggressive and violent behaviours exhibited by patients since the implementation of the NEAT in an ICU, (ii) identify the characteristics of patients exhibiting such behaviours, and (iii) determine the healthcare professionals most at risk of being subjected to occupational violence in this setting.