Thursday, 27 July 2017

Prevention and management of patient and visitor aggression in general hospitals

Nurse managers: Determinants and behaviours in relation to patient and visitor aggression in general hospitals. A qualitative study

Birgit Heckemann

Patient and visitor aggression (PVA) in general hospitals is internationally recognized as a problem that requires urgent attention. A large international body of research has to date investigated the perception and experiences of nursing staff with PVA (Lanctôt & Guay, 2014). However, little is known about how nurse managers experience and manage PVA, although the link between leadership, workplace safety, job satisfaction and quality of care has been recognised (Farrell, Touran, & Siew-Pang, 2014; Feather, Ebright, & Bakas, 2015).

This qualitative descriptive interview and focus group study explored nurse managers' behaviours, attitudes, perceived social norms, and behavioural control in the prevention and management of patient and visitor aggression in general hospitals. The study is part of a sequential mixed methods research project aimed at obtaining an international overview of PVA from a managers' perspective (Hahn et al., 2016).

Using the Reasoned Action Approach (Fishbein & Ajzen, 2010) as a theoretical underpinning for data collection and content analysis of 13 interviews and five focus groups, we identified three main themes: (1) Background factors: ‘Patient and visitor aggression is perceived through different lenses’; (2) Determinants and intention: ‘Good intentions competing with harsh organizational reality’; (3) Behaviours: ‘Preventing and managing aggressive behaviour, and relentlessly striving to create low-aggression work environments’.

Our key findings were:
  • Managers' behaviours depend on whether patient and visitor aggression is perceived from a situational and/or organizational perspective.
  • Existing communication channels between nursing staff and managers should be strengthened. Particularly formal incident reporting is underutilized as a tool to document and communicate aggressive incidents within the organization.
  • Nurse managers face substantial challenges in addressing patient and visitor aggression at an organizational level. This is due to a lack of financial resources and awareness within the organization.
Addressing patient and visitor aggression is challenging for nurse managers due to lack of coordination between the situational management of individual aggressive incidents and organizational feedback loops, protocols and procedures. Further challenges include a scarcity of financial resources and lack of interest in the topic across the organization. Being able to present patient and visitor aggression as a quality issue and business case might help to raise awareness and support within the organisation. Furthermore, clear communication about expectations, needs and available resources between staff and nurse managers could facilitate adequate support provision for

Birgit Heckemann
RN, MSc, PhD student
CAPHRI, Maastricht University


Farrell, G., Touran, S., & Siew-Pang, C. (2014). Patient and visitor assault on nurses and midwives: An exploratory study of employer ‘protective’ factors. International Journal of Mental Health Nursing, 23(1), 88–96. doi:10.1111/inm.12002

Feather, R., Ebright, P., & Bakas, T. (2015). Nurse manager behaviors that RNs perceive to affect their job satisfaction. Nurs Forum, 50(2), 125-136. doi:10.1111/nuf.12086.

Fishbein, M., & Ajzen, I. (2010). Predicting and Changing Behavior: The Reasoned Action Approach. New York: Taylor & Francis.

Hahn, S., Heckemann, B., Gerdtz, M., Hamilton, B., Riahi, S., Thomson, G., . . . De Santo Iennaco, J. (2016). PERoPA – the nursing managers’ perspective. Retrieved from Research Project Information: PERoPA – the nursing managers’ perspective website:

Heckemann B, Peter KA, Halfens RJG, Schols JMGA, Kok G, Hahn S. Nurse managers: Determinants and behaviours in relation to patient and visitor aggression in general hospitals. A qualitative study. J Adv Nurs. 2017;00:1–11.

Lanctôt, N., & Guay, S. (2014). The aftermath of workplace violence among healthcare workers: A systematic literature review of the consequences. Aggress Violent Beh., 19(5), 492-501. doi:

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