AGGRESSION AND TRANSGRESSIVE BEHAVIOUR IN CARE

TINA VANDECASTEELE

AGGRESSION AND TRANSGRESSIVE BEHAVIOUR IN CARE RELATIONSHIPS

BETWEEN NURSES AND PATIENTS

Supervisor: Prof. dr. Sofie VerhaegheCo-supervisor: Prof. dr. Ann Van Hecke

THAT’S HOW THE LIGHT GETS IN.

Leonard Cohen

THERE IS A CRACK IN EVERYTHING.

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Opgedragen aan mémé, Julia D’Haene

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AGGRESSION AND TRANSGRESSIVE BEHAVIOUR IN CARE RELATIONSHIPS:

Influencing factors and underlying processes in nurses’ and patients’

perceptions

PhD thesis Ghent University

Copyright © 2018, Tina Vandecasteele

Verschenen in de reeks monografieën van de Vakgroep Maatschappelijke Gezondheidkunde,

Universiteit Gent

All rights reserved. No parts of this book may be reproduced or transmitted in any form or by any means,

electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the authors.

ISBN: 9789073626874D/2018/3988/8

TINA VANDECASTEELE

AGGRESSION AND TRANSGRESSIVE BEHAVIOUR IN CARE RELATIONSHIPS:

Influencing factors and underlying processes in nurses’ and patients’ perceptions

Supervisor: Prof. dr. Sofie VerhaegheCo-supervisor: Prof. dr. Ann Van Hecke

Dissertation submitted in fulfilment of the requirements for the degree of PhD in Health Sciences.

Academic Year 2017-2018

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Supervisor

Professor Dr. Sofie Verhaeghe

University Centre for Nursing and Midwifery

Department of Public Health - Faculty of Medicine and Health Sciences

Ghent University, Belgium

Co-supervisor

Professor Dr. Ann Van Hecke




Other members of the guidance committee

Professor Dr. Dimitri Beeckman




Professor Dr. Em. Maria Grypdonck




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Examination committee

Professor Dr. Ruth Piers

Department of Internal Medicine

Faculty of Medicine and Health Sciences


Professor Dr. Kurt Audeanert

Department of Psychiatry and Medical Psychology



Dr. Els Steeman

Department of Geriatrics

AZ Nikolaas, Belgium

Dr. Peter Pype

Department of General practice and primary health care



Professor Dr. Wilfried Schnepp

Department for Family-Oriented and Community-Based Nursing

Institute of Nursing Science

University of Witten/Herdecke

Professor Dr. Rudy Van den Broecke - chairman

Department of Uro-gynaecology



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TABLE OF CONTENTS

Chapter I.

INTRODUCTION 13

1 | General introduction 15

1.1. | The problem of aggression in healthcare 16

1.2. | Challenges in addressing aggression in healthcare 22

1.3. | General objectives and outline of this dissertation 25

Chapter II.

ASSESSMENT OF AGGRESSION IN CARE RELATIONSHIPS: VALIDATION OF

THREE INSTRUMENTS 37

1. | Introduction 40

1.1. | Background 40

1.2. | Assessment of patients’ and family members’ aggression in general hospitals 41

2. | The study 43

2.1. | Aims 43

3. | Results 45

3.1. | Phase I: Translation and adaption of the SOVES, POAS-s and POIS 45

3.2. | Phase II: Assessment of psychometric properties of the Dutch version of the

SOVES, POAS-s and POIS 45

4. | Discussion 48

4.1. | Implications for nursing management 50

5. | Conclusion 51

Chapter III.

EXPERIENCES AND PERCEPTIONS OF AGGRESSION OF NURSES WORKING

IN PRIMARY CARE AND GENERAL HOSPITAL SETTINGS 59


2. | The study 65

2.1. | Aims 65

2.2. | Design 65

2.3. | Participants 65

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2.4. | Data collection 66

2.5. | Data analysis 67

2.6. | Ethical considerations 68

3. | Results 68

3.1. | Comparison of nurses’ experiences and perceptions of patient aggression and aggression by patients’ family members in primary care and general hospital setting 69

3.2. | Identifying associations between nurses’ characteristics and perceptions regarding aggression and its management 75

4. | Discussion 79

4.1. | Methodological considerations 82

5. | Conclusion 83

Chapter IV.

PATIENTS’ PERCEPTIONS OF TRANSGRESSIVE BEHAVIOUR IN CARE

RELATIONSHIPS WITH NURSES 91


2. | The study 97

2.1. | Aim 97

2.2. | Design 97

2.3. | Participants 97




2.7. | Rigour 99

3. | Results 100

3.1. | Framework of suppositions: ‘Competent care and human interaction, surely that is self-evident?’ 100

3.2. | Experiencing discrepancies: ‘Competent care and human interaction, is it not self-evident after all?’ 101

3.3. | And now what?: ‘Apparently, competent care and human interactions are not self-evident’ 103

3.4. | Integration: What (exactly) is transgressive (behaviour)? 106

4. | Discussion 107

4.1. | Interpretation and context of the results 108

4.2. | Limitations 109

5. | Conclusion 110

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Chapter V.

NURSES’ PERCEPTIONS OF TRANSGRESSIVE BEHAVIOUR IN CARE

RELATIONSHIPS WITH PATIENTS 115



2. | The study 120

2.1. | Aim 120

2.2. | Design 120

2.3. | Sample 120




2.7. | Rigour 122

3. | Results 123

3.1. | Determining factors 123

3.2. | Regulating factors 125

4. | Discussion 128

4.1. | Interpretation and context of the results 129

4.2. | Limitations 131

4.3. | Implications for practice 131

4.4. | Implications for further research 132

5. | Conclusion 133

Chapter VI.

INFLUENCE OF TEAM MEMBERS ON NURSES’ PERCEPTIONS OF

TRANSGRESSIVE BEHAVIOUR 139



2. | The Study 144

2.1. | Aim 144

2.2. | Design 144

2.3. | Sample and participants 144



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2.7. | Rigour 147

3. | Results 147

4. | Discussion 154

4.1. | Interpretation and discussion of the findings 155

4.2. | Implications for policy and practice 157

4.3. | Study limitations 157

5. | Conclusion 158

Chapter VII.

GENERAL DISCUSSION 165


2. | The merit of adopting the concept of ‘transgressive behaviour’ 167

3. | Connecting the nurses’ and the patients’ perspective on transgressive behaviour in care relationships 171

4. | Care relationships in a broader perspective and challenges for healthcare practice 175

5. | Implications and recommendations for nursing practice 179

6. | Recommendations for management 186

7. | Methodological considerations 188

8. | Recommendations for further research 191

SUMMARY 207

SAMENVATTING 213

CURRICULUM VITAE 221

DANKWOORD 229

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Introduction

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Chapter I.

INTRODUCTION

Chapter I

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Introduction

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1 | General introduction

It is two o’clock in the afternoon. You are a patient at the orthopaedics department. Your neighbour has

been complaining of pain for the entire morning and finally asks you to call a nurse. You call a nurse,

but nobody shows up. After half an hour you get out of bed and walk to the nurse station. A few nurses

approach while they are talking and laughing. You get angry, how dare they make you wait for so long,

all the while your neighbour is in pain. In a loud and angry voice you tell them that you need a nurse

right now as your neighbour is in severe pain. One of the nurses replies she will come in a minute. You

return to your room, and wait. After another ten minutes, a nurse enters your room and tells you you

ought to be more polite in the future.1

The focus of this dissertation is broadly portrayed in this example. This example highlights different

aspects of aggression in healthcare, referring to the different perspectives in aggressive incidents and

the interactional component of aggression in care relationships. Compared to general workers,

healthcare workers have been identified as the group of employees most at risk of aggression, with

nurses prominent on the at-risk list (Wells & Bowers 2002; Estryn-Behar 2008; Wei, Chiou, Chien, &

Huang, 2016). Aggression towards nurses can arise from different sources. Research focused on

aggression of patients to nurses (Farrell & Shafiei 2012; Waschgler et al., 2013; Arnetz et al., 2015), of

family members to nurses (Lin & Liu, 2005; Hahn et al., 2012; Pich, Hazelton, & Kable 2013), of nurses

to nurses (Rowe & Sherlock, 2005; Johnson, 2009; Trépanier, Fernet, Austin, & Boudrias, 2016), and

of doctors or allied health professionals to nurses (Sofield & Salmond, 2003; Farrell & Shafiei, 2012;

Hamblin et al., 2016). This dissertation will primarily focus on the first source, namely aggression

towards nurses perpetrated by patients.

In this introduction, aggression in interpersonal relationships in healthcare including the problem of

aggression in healthcare, and the challenges in addressing aggression in healthcare will be touched

upon. Further on, the aim of the dissertation, the research objectives and an overview of the different

chapters of this dissertation will be given.

1 An experience brought by a participant (chapter IV)

Chapter I

16

1.1. | The problem of aggression in healthcare

Aggression in healthcare is not a new phenomenon, and not a new problem. When exploring aspects

of aggression in healthcare, it is important to define the concept of aggression. The word aggression

origins from the early 17th century from the Latin word aggressio(n-), from aggredi ‘to attack’ (Edward,

Ousey, Warelow, & Liu, 2014). Transferring the concept of aggression to a healthcare context has

induced a lot of different definitions of aggression, and a great deal of ambiguity and inconsistency in

defining this concept. This difficulty in defining aggression is related to the subjective aspects of

aggression (Rippon, 2000) and the multidimensionality and complex multifactorial nature of this concept

(Cutcliffe & Riahi, 2013). A cursory review of the used definitions of aggression in general literature

demonstrates diversity in defining this concept. On a more conventional or general level, the Oxford

Dictionary defines aggression as ‘feelings of anger or antipathy resulting in hostile or violent behaviour,

a readiness to attack or confront’. In earlier and rather general definitions, aggression is described as

‘an act whose goal-response is injury to another organism’ (Dollard et al., 1939 in Berkowitz 1989) or

‘any form of behaviour directed towards the goal of harming or injuring another living being who is

motivated to avoid such treatment’ (DeWall, Anderson, & Bushman, 2011). And another definition of

aggression is ‘behaviour that harms regardless of the intention of the aggressor’ (Richardson &

Hammock 2011; Edward et al., 2014). These definitions refer to ‘human aggression’ on a somewhat

general level. More recently, in defining aggression in a more specific healthcare context, aggression is

comprehensively described as ‘a negative expression of inner anxiety, which can adopt a physically

violent form, aimed at oneself, others or the material environment, or can have a verbal nature which

amounts to insulting, provocation or threatening behaviour’ (Wittouck, Audenaert & Vander Laenen,

2015) . Rippon (2000) proclaims a clear and agreed upon definition of aggression needs to be

established and compared different definitions across different contexts and studies. He concluded that

certain factors appeared to be constant in research and publications on the subject of aggression. These

factors include intent on the part of the aggressor, a cognitive process, and physical, psychological

and/or emotional harm resulting from the behaviour (Rippon, 2000). Despite the notion that there is no

universal definition of aggression and therefore no common comprehension of what constitutes

aggression, there is a plethora of research on the topic of aggression in healthcare. In addressing

aggression in healthcare, research has focused on the exposure of nurses to aggression and its

Introduction

17

prevalence, the consequences of experiencing aggression and the causes of aggression in care

relationships.

In focusing on nurses exposure to aggression, a recent review of Spector, Zhou, and Che (2014),

which provided data on 151.347 nurses from 160 samples, reported overall exposure rates of 36.4% for

physical aggression, 66.9% for nonphysical aggression, and 25% for sexual harassment (Spector et al.,

2014). Rates of exposure appeared to vary by world region, and varied in the source of aggression, with

patients accounting for most of it in Anglo (Gerberich et al., 2004; Hegney, Tuckett, Parker, & Eley,

2010) and European regions (Estryn-Behar et al., 2008; Gascón et al. 2009), whereas patients’ families

or friends were the most common source of aggression towards nurses in the Middle East (Esmaeilpour,

Salsali, & Ahmadi, 2001). These nurses exposure rates are broadly similar to those reported in other,

albeit smaller samples in European studies (Camerino et al., 2008; Estryn-Behar et al. 2008; Hahn et

al., 2010; Magnavita & Heponiemi, 2011).

The majority of studies focusing on nurses’ exposure to patient aggression were conducted in mental

health (Duxbury, 2002; Edward et al., 2015), geriatric (Zeller et al., 2009; Duxbury, Pulsford, Hadi, &

Sykes, 2013) or emergency departments (Campbell et al., 2011; Hahn et al., 2013; Wei et al., 2016).

Other settings like general hospital wards (Hahn et al., 2008; Hahn et al., 2011), paediatrics (Pich,

Hazelton, Sundin, & Kable, 2011; Pich et al., 2013), community (Geiger-Brown et al., 2007; da Silva et

al., 2015) or ambulatory care (Hahn et al., 2013) have been studied to a lesser extent. Nevertheless,

across different countries, different studies, and different contexts, research on aggression in nursing

suggests patient aggression is a problem in most -if not all- nursing settings. This particular vulnerability

of nurses is believed to be related to the frequent and longer contacts with patients and their families as

nurses are responsible for providing direct care (Catlette, 2005). Consequently, the nature, the duration

and the intensity of the care relationship with patients or their families appears to make nurses more

prone to experience aggression during their occupation (Gerberich et al., 2004; Abderhalden et al.,

2007; Waschgler et al., 2013).

Because of the increased risk that nurses face in encountering aggression during their occupation, there

has been an interest in research to understand the consequences of experiencing aggression. A

number of documented consequences have been linked to aggression in healthcare, pointing out how

the occurrence of aggression causes harm to the individual nurses, the quality of patient care, and the

organisation as a whole. Individual nurses are placed at an increased risk of injury, low morale, feelings

Chapter I

18

of vulnerability (Arnetz & Arnetz, 2001; Fry, O’ Riordan, Turner, & Mills, 2002), sleep disturbances, loss

of self-confidence (May & Grubbs, 2002), and other consequences that compromise the physical and

psychological well-being of nurses (Needham et al., 2005; Hahn et al., 2008). These consequences

even affect caregiving for future patients as research points out how nurses experience a loss of

empathy towards patients (Pich et al., 2011), increase avoidance with fewer contacts with patients

(Luckhoff et al., 2013), adopt a passive role (Needham et al., 2005), become less eager to spend time

with patients or become less willing to answer patient’s call lights (Gates, Fitzwater, & Meyer, 1999).

Consequences of experiencing aggression on the quality of patient care have been studied in a cross-

sectional study of Roche et al. (2010), pointing out how patient aggression was associated with falls,

medication errors and late administration of medications. However, Roche et al. (2010) also observed

how tensions in the work environment attributed to this observed association and hypothesised how

aggression is also related to specific unit circumstances, like for instance ward instability. Moreover,

consequences of patient aggression have also been studied on an organisational level. Several

studies have pointed out how organisations are faced with increased absenteeism (Foster, Bowers, &

Nijman, 2007; Nijman, Bowers, Oud, & Jansen, 2005), reduced job motivation (Arnetz & Arnetz, 2001;

Hahn et al., 2010; Needham et al., 2005), and increased staff turnover rates (Sofield & Salmond, 2003,

Clausen, Hogh, Carneiro, & Borg, 2013; Luckhoff et al., 2013) when being confronted with patient

aggression. These consequences are all detrimental especially in current times of nursing shortage

(Jackson, Clare, & Mannix, 2002; Camerino et al., 2008).

Alongside and inspired by research on the consequences of patient aggression on nurses, patient care

and the organisation, there has been an increased interest in understanding what causes patient

aggression. Irrespective of a healthcare context, psychologists have proposed a variety of theories to

understand why people sometimes behave aggressively. Five main theories of aggression guide most

research, and include the cognitive neoassociation theory (Berkowitz, 1989, 1990, 1993), social learning

theory (Bandura 1983, 2001), script theory (Huesmann 1986, 1988), excitation transfer theory (Zillmann

1983), and social interaction theory (Tedeschi & Felson 1994). With regard to the specific healthcare

research in this area, different theories have been developed that endeavour to explain what causes

patients to behave aggressively in a healthcare context. To provide a first general overview, three broad

conceptual models on the causation of patient aggression will be introduced: the internal, external,

and situational or interactional model (Nijman, 2002; Duxbury, 2002; Duxbury & Whittington, 2005). The

Introduction

19

main suppositions of these models explaining causes of patient aggression are discussed, connecting

these to identified risk factors for caregivers to encounter aggression. Subsequently, several theoretical

frameworks which recognise the multifactorial nature of aggression encompassing the three conceptual

models, will be briefly presented.

Internal model. According to Duxbury and Whittington (2005), research studies examining patient

aggression that are underpinned by this model are prevalent. In this particular model, individual patient

variables are believed to be the cause of aggression. This perspective has induced a lot of research to

focus on the link between aggression and particular (demographic) features of perpetrators of

aggression. Risk factors for aggression on the patients’ level have been identified, e.g. health disorders,

severe psychopathology or thought disorders (Nijman, 2002; Ayranci et al., 2006; Podubinski, Lee,

Hollander, & Daffern, 2017), intoxication because of drug and/or alcohol use (Gacki-Smith et al., 2009;

Pompeii et al., 2013), cognitive problems with advanced age (Gacki-Smith et al., 2009; Gates, Ross, &

McQueen, 2006; Hahn et al., 2013), repeated hospital admissions (James, Madeley, & Dove, 2006), or

a history of aggression towards caregivers (Reed, 1997). As a result, diagnosis and age are by far the

most frequently researched demographic variables to explain the causes of patient aggression. Whilst

features of the internal model are attractive because of the relatively fixed nature of these variables, the

predictive value of such variables keeps being called into question (Duxbury & Whittington, 2005).

External model. The external model opposes the internal model and asserts that environmental factors

contribute to the occurrence of patient aggression. Accordingly, issues that have been explored include

building deficits such as limited space or provisions of privacy, time of the day, type of regime,

overcrowding, and the impact of unit design (Duxbury, 2002; Gates et al., 2006; Gillespie, Gates, Miller,

& Howard, 2010). For instance, Pompeii et al. (2013) pointed out how long waiting times (Ayranci et al.,

2006; Gacki-Smith et al., 2009; Gates et al., 2006) and overcrowding (El-Gilany et al., 2010; Gacki-

Smith et al., 2009) were environmental conditions present at the time of an aggressive incident. External

factors as staff characteristics are also believed to have an impact upon the incidence of patient

aggression. A review of Gillespie et al. (2010) pointed out how caregivers’ gender (Ayranci et al., 2006;

Hegney et al., 2006; Camerino et al., 2008), age (Ayranci et al., 2006; Camerino et al., 2008; Thomas

et al., 2006), years of working experience (Ergün & Karadakovan, 2005), hours worked (Thomas et al.,

2006; Hegney et al., 2006), marital status (Lin & Liu, 2005), and previous workplace aggression training

(Ergün & Karadakovan, 2005) have been found to increase the risk of caregivers being targets of

Chapter I

20

aggression. However, Gillespie and colleagues (2010) do conclude that identifying healthcare workers

most at risk of experiencing aggressive events based on their characteristics is difficult because

research findings on these external factors are inconsistent.

Interactional/situational model. This model supposes it is important to examine the interaction

between groups of variants that incorporate both internal and external factors when exploring the

problem of patient aggression in healthcare. The impact of combined factors that have a negative

influence on staff-patient relationships is recognized in the situational model. A number of studies

support the view that negative staff and patient relationships might lead to patient aggression (Nijman,

2002; Duxbury, 2002). In examining research on ecologic factors influencing the likelihood of inpatient

unit aggression, Hamrin, Iennaco, & Olser, (2009) pointed out how staff who were more authoritative

and detached towards patients were more prone to aggressive encounters. Whereas staff who engaged

with patients in early intervention, were psychologically available to patients, understood patients’

perspectives and demonstrated compassionate attitudes, encountered fewer aggressive incidents

(Hamrin et al., 2009). In Duxbury et al. (2013) nurses’ perspectives towards aggressive behaviour of

older people with dementia were explored, pointing out how aggressive behaviour is largely an

interpersonal phenomenon and interactions between staff and patients are a significant cause for

patients’ aggressive responses. When aggressive behaviour arose, nurses attributed this to interactions

with other residents, or the person being denied something by staff. This perspective encompassing

situational factors as significant triggers for aggression has also been observed in other studies (Almvik,

Rasmussen, & Woods, 2006; Whall et al., 2008).

The division in these three models is interesting as it provides a tentative overview of beliefs about the

complex reasons leading to patient aggression. An understanding of beliefs towards patient aggression

is important as the way patient aggression is understood influences the way aggression is managed. As

Duxbury (2002) proclaims, the internal perspective in the internal model prevails which may contribute

to the perpetuated use of medical interventions (f.i. chemical restraint) to manage patient aggression.

Whereas if aggression is perceived as an interpersonal and situational phenomenon, a response by

interpersonal means might be preferred, in being aware of own contributions in triggering aggression

(MacDonald et al., 2007). Nevertheless, one can criticise it is difficult to make distinctions between what

is internal and external to the individual or part of the overall situation and subsequent interactions

(Duxbury & Whittington, 2005). Even though these three models are presented as distinct models, it is

Introduction

21

imperative to note there is an important interaction between these models. Risk factors for aggression

identified in the internal model might make a person more likely to engage in aggressive behaviour.

However, an individual propensity for aggression still needs to be triggered. Immediately, this points

towards the range of situational factors, identified in the conceptualization of the external and

interactional model. For example, in a study about aggression towards healthcare workers in a paediatric

emergency department, Gillespie et al. (2008) identified patients’ and families’ inability to deal with a

crisis situation to be a risk factor for aggression. However, in considering the context and characteristics

of paediatric emergencies, it is important to understand patients’ or families’ behaviour, even if it is

aggressive, from both an internal, external and situational model. Consequently, the division in three

broad conceptual models is interesting, but an interrelation between these models needs to be

acknowledged to generate a comprehensive understanding of patient aggression. This

acknowledgement of different factors contributing to patient aggression is present in the existing

theoretical frameworks regarding patient aggression in healthcare. These frameworks acknowledge the

complexity of the interrelation of different risk factors in explaining why patients behave aggressively in

a healthcare context. Most theoretical frameworks on aggression in healthcare consider aggression to

be a complex and multi-faceted phenomenon, with a variety of triggering factors, behaviours, and

consequences beyond the individual perpetrator. For instance, Nijman’s model, in trying to shed light

on the mechanisms that lead to aggression, elucidates how certain patient, staff and ward characteristics

may interact in causing patient aggression (Nijman, 2002). Likewise, Hamrin and colleagues pointed out

how aggression in inpatient mental health units results from a multitude of factors, including individual

patient and staff factors, the complex interaction between patients and staff, and the unit and

organizational culture (Hamrin et al., 2009). The Safewards model of Bowers (2014) also uses a

comprehensive structure in referring to a dynamic interaction between staff modifiers and patient

modifiers, which may lead to conflict and containment on mental health wards. Even though most of

these theoretical frameworks have been developed in specific settings like the mental healthcare setting

(Nijman, 2002; Hamrin et al., 2009; Bowers, 2014), they provide a set of explicable principles about

patient aggression which could be transferred to other healthcare settings. Although there are inherent

differences among various healthcare settings, transferring insights can be based on the similarity that

care is provided for patients in vulnerable situations. And in addition, the notion that patient aggression

occurs in interpersonal care relationships, irrespective of the context of the specific healthcare setting.

Chapter I

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1.2. | Challenges in addressing aggression in healthcare

Despite the important insights generated through the extant research on aggression in healthcare, some

issues regarding aggression in care relationships remain unclear or under-researched. These

issues induce challenges in understanding aggressive behaviour in care relationships. These issues

pertain to a scarcity of knowledge on aggression in more general hospital settings, a paucity of insight

into patients’ perspectives of aggression, a limited to no insight into perceptions or meanings of

aggression, and a lack of insight into team dynamics in nursing teams in processing patient aggression.

These issues will be elaborated upon below.

Knowledge on the occurrence of patient aggression in more general settings. As mentioned

before, the problem of aggression towards nurses has been a subject of research for decades. Most

studies have focused on geriatric (Almvik et al., 2006; Duxbury et al., 2013), emergency (Gerdtz et al.,

2013), and mental healthcare settings (Abderhalden et al., 2007). Little knowledge is available about

patient aggression in more general medical and surgical care units or in primary care. Because of some

differences, self-evidently generalizing results from for instance emergency settings to general hospitals

or primary care might induce challenges (Winstanley & Whittington, 2004). For example, the specific

nurses’ work climate in primary care might influence the occurrence of patient aggression as nurses

often perform activities outside health centres (such as private home visits), generally work alone (da

Silva et al., 2015) and cannot rely on the protection that is present in hospital settings (e.g. the presence

of colleagues, alarm systems) (Geiger-Brown et al., 2007). Likewise, according to Roche et al. (2010),

general hospital settings are increasingly regarded to be vulnerable for aggressive incidents. Few

studies focused on the occurrence of patient aggression in general hospital settings (Hahn et al., 2013;

Heckemann et al., 2015). Although the work of Hahn (2011) has made a significant contribution to the

understanding of patient and visitor violence in general hospital settings in Switzerland and other

German-speaking countries, much can still be learned about the occurrence of patient aggression in the

former settings (Winstanley & Whittington 2004; Wei et al., 2016). So far, scarce initiatives have been

undertaken to focus on patient aggression in a general hospital setting or in primary care in Belgium.

Insight into patients’ perspectives of aggression. Even though there is a plethora of research on

aggression in healthcare, surprisingly little is known about the patient’s perspective regarding

aggression in care relationships. Despite concerns about ethical dilemmas associated with exploring

patient perspectives (Duxbury & Whittington, 2005), it is necessary to understand how patients construe

Introduction

23

care relationships with caregivers and how they experience aggressive or negative interactions with

caregivers. The focus in research on aggression in healthcare is rather unilateral as the majority of

research starts off with the caregivers’ perspective and explores caregivers’ experiences of patient

aggression (Jansen, Dassen, Groot, & Jebbink, 2005; Gale et al., 2009; Farrell & Shafiei, 2012). Few

studies adopt the patients’ perspective (Duxbury, 2002; Duxbury & Whittington, 2005) to understand

how patients might experience negative, aggressive or untoward behaviour of caregivers. Exploration

of patients’ perspectives is important as professional staff and researchers will tend to see the world in

a particular way, and thus are likely to be more or less ignorant of how patients experience the world

(Gudde, Olso, Whittington, & Vatne, 2015). Directly comparing both patients’ and staff’ perspectives on

the causes of aggression, Duxbury and Whittington (2005) pointed out how both perspectives differ

significantly.

On a more general level, patients’ views of healthcare are considered an essential component of health

service evaluations. They are used to assess how well services are provided at a local level (McPherson,

Kayes, Moloczij, & Commins, 2014), to obtain feedback to healthcare workers to improve quality of care

(Cominskey, Coyne, Lalor, & Begley, 2014), or as an outcome measure to evaluate organizational

changes (Metzelthin et al., 2013). In literature and in practice, patient satisfaction surveys are regarded

as a valid method to obtain patients’ views of healthcare and are as such frequently used (You et al.,

2013; Lehto, Helander, Taari, & Aromaa, 2014). Alongside the reservations that exist about the validity

of patient satisfaction as a concept and the instruments used to measure it (William 1994), patient

satisfaction surveys do not seem sensitive enough in eliciting disappointment, negative experiences or

untoward and aggressive behaviour of caregivers (Coyle & Williams, 2001). Therefore, it is important to

gain insight into the patient’s perspective regarding aggressive or negative interactions with healthcare

staff. And in literature, the importance of drawing on experiences of both staff and patients if one wishes

to understand aggression in care relationships in a comprehensive way, is acknowledged (Gudde et al.,

2015).

Insight into perceptions and the meaning of aggression. As previously mentioned, the internal,

external and interactional model on causes of aggression refers to reasons as to why patients can

behave aggressively in a healthcare context (Nijman, 2002; Duxbury, 2002; Duxbury & Whittington,

2005). These entailed different viewpoints of aggression and aggressive behaviour which impact the

nature of the approach to managing aggressive incidents (Jansen et al., 2005; Duxbury, Hahn,

Chapter I

24

Needham, & Pulsford, 2008). Although this relation between perceptions of aggression and intervention

strategies in managing aggression is acknowledged, little is known about how nurses perceive and think

about patient aggression (Winstanley & Whittington, 2004; Catlette, 2005; Needham et al., 2005). Just

a few instruments are available to assess perceptions of aggression. For instance, the (shortened

version of the) Perception of Aggression Scale (Jansen, Dassen, & Moorer, 1997; Needham et al.,

2004), the Attitude towards Aggression Scale (Jansen et al., 2005), and the Management of Aggression

and Violence Attitude Scale (Duxbury, 2002) are some instruments to assess perceptions, attitudes or

beliefs towards aggression. These kind of instruments typically adopt statements about or definitions of

aggression as starting-points to explore participants’ perceptions about aggression. Although this

approach renders relevant information in assessing perceptions of aggression, a discernible difficulty

arises. When statements or definitions of aggression are used, the concept of aggression is represented

as a measurable, uniform phenomenon, free of context and meaning. There is a basic assumption that

the same statements about the phenomenon of aggression have the same meaning for all subjects,

which can be understood as way of objectifying the phenomenon of aggression. However, surveying

the phenomenon of aggression in this objectifying approach sidesteps the notion that perceptions of

what aggression means, vary between persons. Aggression means something that is different for

various individuals as the specific context, and assigned meaning of aggression take on a crucial role

in how aggression is perceived (O’Connell et al., 2000; Duxbury, 2003). This means that the subjective

experience of aggression, with an inherent diversity among individuals, cannot easily be integrated in

statements, measurement instruments or definitions of aggression. However, at present, no insight

exists on the subjective meaning of aggression in care relationships between nurses and patients.

Insight into team dynamics in nursing teams in addressing patient aggression. In addressing

nurses’ perspectives of aggression in care relationships, most studies focus on the perspective of

singular nurses. Group dynamics and interactions with other team members that can influence individual

nurse’s experiences are scarcely taken into consideration. The influence of team members and group

interactions can be essential as research has noted how peer pressure from other nursing staff appears

to be one of the reasons incidents are not reported (Rippon, 2000, Sato, Wakabayashi, Kiyoshi-Teo, &

Fukahori, 2013). This finding suggests nurses can be affected or even swayed by colleagues with

regards to perceiving, managing or eventually reporting aggression. Reasons as to why and how nurses

are influenced by colleagues can be found in literature on socializing processes in nursing teams

Introduction

25

(Bisholt, 2012; Feng & Tsai, 2012; Thrysou, Hounsgaard, Dohn, & Wagner, 2012). The concept

‘professional socialization’ (Mooney, 2007; Bisholt, 2012) refers to processes through which

practitioners are merged into the profession (Mooney, 2007). This process entails that newcomers

gradually acquire attitudes, values, and norms of professional clinical practitioners (Mooney, 2007; Feng

& Tsai, 2012) while learning (in)formal rules of the organisation (Maben, Latter, & Clark, 2006). These

studies commonly focus on experiences of recently qualified nurses (Bisholt, 2012) or Baccalaureate

nursing students (Secrest, Norwood, & Keatley, 2002). It can be hypothesized that similar processes of

socialisation remain present in nurses who have been working for some time in nursing practice

(Yarbrough, Martin, Alfred, & McNeill, 2016). Likewise, it remains unclear how these processes influence

patient’s care or the conduct towards patients following experiences of patient aggression. There is little

knowledge at hand surrounding nurses’ interactions and team dynamics in perceiving and addressing

patients’ aggressive behaviour.

1.3. | General objectives and outline of this dissertation

This dissertation aims to contribute to the literature on aggression in care relationships by providing

tentative answers to these various presented challenges. This dissertation will focus on under-

researched nurses’ work settings, use both an objectifying and a subjectifying approach in

understanding aggression in care relationships, adopt both the nurses’ and patients’ perspective in

perceiving aggression, and examine group dynamics in nursing teams in perceiving and addressing

patient aggression. The studies discussed in this dissertation are divided into two major parts, and

guided by different research objectives. These will be further explained below.

To gain knowledge on the occurrence of patient aggression in more general settings and nurses ’

perceptions of aggression, the first part of this dissertation focuses on gaining a broad indication of

nurses’ experiences of aggression in the general hospital setting and in primary care in Belgium. An

assessment instrument was needed to provide information on frequencies and characteristics of patient

aggression, and nurses’ perceptions of aggression working in these settings. In chapter II, the

translation and psychometric validation of three assessment instruments is addressed, formulating

following research objectives:

To translate the Survey of Violence Experienced by Staff (SOVES), the shortened Perception

of Aggression Scale (POAS-s) and the Perception of Importance of Intervention Skills Scale

(POIS) and adapt these instruments for use in general hospital settings.

Chapter I

26

To assess psychometric properties (content validity, construct validity, stability, and internal

consistency) of the translated versions of these instruments in general hospital settings.

Following the translation and psychometric validation of these assessment instruments, chapter III

outlines the results of a cross-sectional study. This cross-sectional study focuses on nurses’ experiences

of patient aggression and aggression by patients’ family members in primary care and in general hospital

settings. In addition, factors associated with nurses’ perceptions of aggression and its management

were identified through a sample of 769 nurses working in primary care and in general hospital settings.

Following research objectives were formulated:

To compare nurses’ experiences of patient aggression and aggression by patients’ family

members in both primary care and general hospital settings.

To identify associations between patient-related, nurse-related and work-related characteristics

and nurses’ perceptions of aggression and its management.

In the second part of this dissertation, an understanding of the meaning of aggression was sought. In

contrast to the rather objectifying approach towards aggression that was adopted in the previous

chapters, following chapters adopt a more subjectifying approach of the concept of aggression. A

subjectifying approach focuses on a form of inductive reasoning to understand aggression in healthcare,

and consequently, how perceptions of aggression can emerge. In order to reach understanding of the

meaning of aggression, the term ‘transgressive behaviour’ was adopted. The use of this term allows

returning to the ‘essence’ of experiencing aggression, namely a crossing of own limits, standards or

norms. This encompasses a subjective interpretation of when and what limits are exceeded for situations

to be experienced as transgressive. In contrast to a more objectifying approach, a subjectifying approach

does not determine in advance which behavioural acts count as aggression, or which ethical or moral

principles are at stake when perceiving transgressive behaviour. As such, the specific context and

assigned meaning of aggression are integrated in trying to understand the meaning of aggression. This

means that both nurses’ and patients’ own experiences of transgressive behaviour provided the starting-

point to gain an understanding of the meaning of aggression and the explanatory underlying processes

of how these perceptions emerge. Chapter IV addresses the meaning of transgressive behaviour in

care relationships with nurses from the patient’s perspective in a general hospital ward setting,

formulating following research objectives:

Introduction

27

To gain insight into what it is like for patients to experience transgressive behaviour in care

relationships with nurses.

To gain insight into processes or mechanisms that influence perceived seriousness of

transgressive behaviour from the patients’ perspective.

As it was important to gain an understanding of the dynamics of the nurse-patient care relationship, the

nurses’ perspective regarding the onset and meaning of patients’ transgressive behaviour is outlined in

chapter V, which is guided by the following research objectives:

To gain insight into behaviour in the patient-nurse relationship that is perceived as transgressive

from the nurses’ perspective.

To gain insight into processes or mechanisms that influence perceived seriousness of patients’

transgressive behaviour.

As these results pointed out the necessity to understand group dynamics in nursing teams in

perceiving and handling transgressive behaviour, a final chapter VI provides an understanding of the

influence of team members in how nurses perceive and address patients’ transgressive behaviour.

Following broad research objective was formulated:

To explore and understand group dynamics and the influence of team members on how

nurses perceive and deal with transgressive behaviour in care relationships with patients.

A brief overview of the addressed challenges, the used approach of aggression, and the methods

employed in each study is included in table 1, and described in more detail in the subsequent chapters.

The third part of this dissertation, chapter VII, provides a general discussion of the findings of this

dissertation. In addition, the relevance of these findings for nursing practice and nursing management

are outlined. Finally, recommendations for further research are presented.

Chapter I

28

Table 1. Overview of studies and methods in each chapter of this dissertation

Addressed

challenge

Approach

towards

aggression

Theme and corresponding

chapter

Methods

Knowledge on the

occurrence of patient

aggression in more

general settings.

First part: An

objectifying

approach

towards the

concept of

aggression

- Assessment of patients’ and

family members’ aggression

directed towards nurses working

in general hospital settings:

validation of three instruments -

(chapter II).

- Aggression of patients and their

family members directed towards

nurses: Experiences and

perceptions of nurses working in

primary care and general hospital

settings - (chapter III).

- Translation and

psychometric validation of

3 instruments (cross-

sectional study including

238 nurses working in

general hospital settings)

- Cross-sectional study

including 769 nurses

working in primary care

and general hospital

settings

Insight into nurses’

perceptions of

aggression.

Insight into patients’

perspectives of

aggression.

Second part: A

more

subjective

approach by

adopting the

term

‘transgressive

behaviour’

Patients’ perceptions of

transgressive behaviour in care

relationships with nurses - (chapter

IV).

Qualitative study. Semi-

structured interviews with 20

patients. Grounded Theory

approach

Insight into the

subjective meaning of

aggression from the

nurses’ perspective.

Nurses’ perceptions of

transgressive behaviour in care

relationship - (chapter V).

Qualitative study. Semi-

structured interviews with 18

nurses. Grounded Theory

approach

Insight into team

dynamics in nursing

teams in addressing

patient aggression.

The influence of team members on

nurses’ perceptions of transgressive

behaviour in care relationships -

(chapter VI).

Qualitative study. Focus-

group interviews and

individual interviews with 24

nurses. Grounded Theory

approach.

This dissertation is composed of different chapters each representing a standalone paper which has

been published, accepted or submitted for publication in peer-reviewed journals.

Introduction

29

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Assessment of aggression: validation of instruments

37

Chapter II.

ASSESSMENT OF AGGRESSION IN CARE

RELATIONSHIPS: VALIDATION OF THREE INSTRUMENTS

Tina Vandecasteele1.2, Ann Van Hecke1,3, Bart Debyser2, Tine Vanderplancke4,

Tine De Backer2, Dimitri Beeckman1, Sofie Verhaeghe1,2

1 Department of Public Health, Faculty of Medicine and Health Sciences, University Centre for Nursing &

Midwifery, Ghent University, Ghent, Belgium.

2 Department Health care, VIVES University College, Roeselare, Belgium.

3 University Hospital Ghent, Ghent, Belgium.

4 Department Health care, VIVES University College, Kortrijk, Belgium.

Based on a manuscript submitted to the Journal of Nursing Management

Chapter II

38

Assessment of aggression: instrument validation

39

Assessment of patients’ and family members’ aggression directed towards nurses

working in general hospital settings: Validation of three instruments

Abstract

Aim. To psychometrically test the Dutch version of the Survey of Violence Experienced by Staff

(SOVES), the shortened Perception of Aggression Scale (POAS-s) and the Perception of Importance of

Intervention Skills Scale (POIS) for use in general hospital wards.

Background. Experiencing aggression has an important impact on both the professional and personal

lives of nurses. Minimal research focuses on patient aggression in general hospital settings. The

SOVES, POAS-S and POIS are validated instruments to study multiple dimensions of patient violence

at the clinical level in a variety of general hospital settings.

Method. Psychometric properties (content- and construct validity, stability, and internal consistency)

were determined in a cross-sectional study including 238 nurses working in general hospital settings.

Results. The instruments showed good content validity and test-retest reliability. Significant

relationships between encountering patient aggression and patient contact time, patients’ ages, and

nurses’ degrees were observed, suggesting construct validity of the SOVES. Factor analysis of the

POAS-s and POIS identified two-factor structures, explaining 46.7% and 68.5% of the variance.

Cronbach’s alpha of the POAS-s was 0.64 and 0.70, alpha-value of the POIS was 0.88 and 0.84.

Conclusions. The instruments showed acceptable to good psychometric properties, and are

recommended to be used in practice to assess patient aggression in general hospitals.

Implications for nursing management. Nurse managers can use these instruments to assess patient

aggression in particular settings, to analyse factors contributing to patient aggression and consequently

design interventions to support nurses in managing patient aggression.

Keywords. Aggression, general hospital setting, instrument, nursing, psychometrics.

Chapter II

40

1. | Introduction

Patient aggression towards nurses occurs frequently (Spector, Zhou, & Che, 2014). Assessment

instruments are needed to provide specific information on frequencies and differences among places

and times of patient aggression. This article addresses the Dutch translation and psychometric testing

of three instruments to assess patients’ and/or family members’ aggression in general hospitals. Data

were obtained in preparation of a larger assessment of aggression using these instruments in general

hospital settings.

1.1. | Background

Aggression by patients towards healthcare workers is a complex and significant occupational hazard in

hospitals worldwide (Hahn et al., 2008; McPhaul, London, & Lipscomb, 2013). Compared to other

healthcare providers, nurses are at a higher risk of experiencing aggression (International Council of

Nurses, 2006; Arnetz et al., 2015). Substantial research on aggression towards nurses has been

conducted, focusing on prevalence (Camerino et al., 2008; Wei, Chiou, Chien, & Huang, 2016),

determinants (Adib et al., 2002; Hahn et al., 2013), risk factors (Gillespie, Gates, Miller, & Howard,

2010), and consequences (Wells & Bowers, 2002; Sofield & Salmond, 2003). Subsequently, several

factors have been identified to contribute to the occurrence of patients’ and family members’ aggression.

These factors account for particular patients’ and/or family members’ characteristics (Hahn et al., 2013),

staff characteristics (Duxbury, 2002; Jansen, Dassen, & Groot Jebbink, 2005), staff-patient and families

interactions (Winstanley & Whittington, 2004; Winstanley, 2005), and organizational characteristics

(Farrell, Bobrowski, & Bobrowski, 2006). With regard to the latter, some specific clinical areas seem to

be at a particular risk of patient and visitor aggression (Spector et al., 2014). Settings like emergency

departments (Gacki-Smith et al., 2009), geriatric care (Franz et al., 2010) and mental health (Foster,

Bowers, & Nijman, 2007) have been exposed to high frequencies of aggression. However, also general

inpatient settings, like medical and surgical wards, are increasingly regarded to be vulnerable for

aggressive incidents (Roche, Diers, Duffield, & Catling-Paull, 2010). Whilst a number of studies have

addressed aggression in the former specific healthcare settings, only a few have done so for nursing in

general hospital settings (Hahn et al., 2013; Heckemann et al., 2015).


41

1.2. | Assessment of patients’ and family members’ aggression in general hospitals

As classifications, scales and standardized assessment instruments form an integral part of nursing

research and nursing practice (Streiner & Kottner, 2014), an instrument is required to study aggression

towards nurses objectively. A variety of instruments exists to assess aggression in healthcare. Examples

of validated instruments are the Staff Observation Aggression Scale (Palmstierna & Widstedt, 1987),

the Management of Aggression and Violence Attitude Scale (Duxbury, 2003), the Attitudes Toward

Physical Assault Questionnaire (Poster & Ryan, 1989), and the Overt Aggression Scale (Yudofsky et

al., 1986). However, current instruments reflect the aforementioned focus on specific clinical areas as

these instruments have primarily been validated in mental health settings (Nijman et al., 2002; Jansen

et al., 2005), emergency (Barzman et al., 2012), or geriatric settings (Ryser, Duxbury, & Hahn, 2015).

Validated instruments to assess patients’ and/or family members’ aggression in general hospital settings

are scarce. Accordingly, Hahn et al. (2011) formulated a conceptual model encompassing relevant

factors related to patients’ and/or family members’ aggression in general hospitals. Based on this model,

three instruments can been combined to provide a comprehensive representation of patients’ and/or

family members’ aggression in general hospital settings.

The Survey of Violence experienced by Staff (SOVES). The SOVES was originally developed by

McKenna (2004) to gather information on workplace aggression, and to acquire data on involved

healthcare staff, patients and the broader workplace environment. The SOVES explores five themes:

(1) prevalence of aggression, (2) consequences of aggression, (3) reporting of aggression, (4) support

after experiencing aggression, and (5) training in managing aggression; as each of these themes is

related to three manifestations of aggression: verbal aggression, threats and physical aggression.

‘Verbal aggression’ is understood as abusive or offensive language, personally derogatory remarks,

profanity or obscene comments. ‘Threats’ are explained as warnings of intent to injure, harassment,

physical intimidation or threat with a weapon. ‘Physical aggression’ comprises slapping, pinching,

pushing, shoving, spitting, kicking or the use of a weapon. The SOVES provides a comprehensive

representation of aggression as several variables (nurses’ characteristics, patients’ characteristics,

nurses’ experiences of different types of aggression, practice characteristics and broader organizational

characteristics) are assessed. Close-ended questions and Visual Analogue Scales (VAS) are used to

assess these variables. Content validity and internal consistency have been assessed by McKenna

(2004), while feasibility and face validity of the German version of the SOVES have been appraised by

Chapter II

42

Hahn et al. (2011), showing good psychometric properties. The SOVES provides important information

on aggressive incidents in nursing practice. However, literature has emphasized attitude towards patient

aggression to be influential towards intervention strategies in handling patient aggression (Duxbury,

2002). Nurses’ beliefs about causation of aggression influence their approach to manage incidents

(Duxbury, Hahn, Needham, & Pulsford, 2008). As this influential and mediating factor is not included in

the SOVES, both the POAS-s and POIS are important to add to gain a more accurate representation of

aggression in nursing practice.

The shortened Perception of Aggression Scale (POAS-s). The POAS, originally developed by

Jansen et al. (1997), consisted of 30 Likert-scaled statements which express various views regarding

aggression. In 2004, Needham and colleagues derived a shortened version, the POAS-s, consisting of

12 items on a 5-point Likert scale, encompassing two dimensions in perceiving aggression: aggression

as a more dysfunctional/undesirable phenomenon (dimension 1) or as a more

functional/comprehensible phenomenon (dimension 2). Validation of the POAS-s has been assessed

through construct validity (Abderhalden et al., 2002), test-retest reliability, internal consistency

(Needham et al., 2004; Hahn et al., 2011), and content validity (Hahn et al., 2011), providing satisfactory

psychometric properties.

The Perception of Importance of Intervention Skills Scale (POIS). The POIS was developed by

Hahn et al. (2011) to measure perceptions of the importance of intervention skills in managing patient

aggression in a general hospital setting. The instrument consists of nine items reflecting common

prevention and intervention strategies (e.g. verbal communications, setting limits, intervening as a

team), measured on a 10-point VAS-scale. In 2011, a psychometric evaluation was conducted in

assessing internal consistency and construct validity in general hospital settings (Hahn et al., 2011),

emphasizing two dimensions in perceptions about aggression management: structured interventions,

evaluation and reflection to manage aggression (dimension 1), and preventive measures to manage

aggression (dimension 2).

As a combination of these three instruments provide access to relevant factors in assessing patients’

and family members’ aggression in general hospital settings, this study aims to translate and validate

these instruments in general hospital settings.


43

2. | The study

2.1. | Aims

This study aims

to translate the SOVES, POAS-s and POIS and adapt it for use in a general hospital setting and

to assess psychometric properties of the translated version in general hospital settings.

2.2. | Methods

2.2.1. Phase I: Translation and adaption of the SOVES, POAS-s and POIS

Three certified translators, with medical-language translation experience, individually translated the

instruments from German to Dutch. Translations were compared and discussed by the translators,

analysing different proposals until reaching consensus. As a control measure of the translation of the

SOVES and the POAS-S, the English validated version of the SOVES and POAS-S was translated by

a translator with a Master’s degree in Linguistics and Literature, Dutch-English. The researcher expert

panel (TV-AVH-SV) and two Masters of Nursing Science students thoroughly reviewed every item while

comparing translations to the original instruments. Difficulties in translating and discrepancies were

discussed with the translators.

Face and content validity of the instruments was assessed by a panel of seven experts (stage 1). Five

had extensive experience in nursing practice in general hospital settings, four were researchers in the

field of aggression in the healthcare system, and two were very familiar with the theoretical basis of

aggression in care relationships. These experts assessed the content, clarity, feasibility and

comprehensibility of the instruments, the technical and semantic equivalence of the translations, and

discussed the cross-cultural relevance of questions ensuring its relevance to the nursing practice and

healthcare context in Belgium. Subtle differences in the conceptual meaning of words were assessed

and discussed.

The semi-final version of the instruments was then pilot-tested for clarity, feasibility and user-friendliness

in a sample of 13 practicing nurses (stage 2). By being cognitively interviewed, nurses elaborated on

how they interpreted and answered the questions of the questionnaire. They judged the construct and

content of the questions for relevance in their nursing practice or clinical setting. Finally, the researcher

expert panel (stage 3) thoroughly discussed all the proposed changes to the instruments.

2.2.2. Phase II: Psychometric properties of the Dutch version of the SOVES, POAS-s and POIS

Design. A cross-sectional validation study was conducted.

Data collection. Ten general medical and surgical wards in two general hospitals and one teaching

hospital were invited to participate. Data were collected from September 2014 to September 2015. The

researcher explained the study to the head of departments and the head nurses. Each head nurse was

consulted to make practical arrangements to distribute the instruments. Nurses were invited to take part,

Chapter II

44

and were informed through a presentation during team meetings. The instruments had to be completed

within six weeks. To ensure anonymity, instruments were returned in secured boxes at the wards. Every

two weeks, a researcher collected the instruments and provided reminders.

To assess test-retest reliability of the instruments, nursing students, obtaining their Master’s degree

(n=34) and licensed practice students obtaining their Bachelor’s degree (n=47) with both experience in

nursing practice were invited to participate. The interval between the test and retest was four to five

hours.

Ethical considerations. Nurses were informed participation was voluntary and responses were treated

anonymous. The study was approved by the Ethical Committee of the Ghent University Hospital

(B/670201421265) and the local Ethical Committees of the hospitals.

Statistical analysis. Descriptive statistics were used to describe nurses’ demographic and professional

characteristics. Negatively worded items of the POAS-s and POIS were reversed before analysis.

Construct validity of the SOVES was assessed by the known-groups technique (Polit & Beck, 2017).

Literature suggests different groups can be expected to differ on the frequency of experiencing

aggression (table 1). Although the SOVES encompasses several major themes, only the frequency of

encountering aggression was chosen to provide an indication of construct validity. Chi-square tests were

used to compare group scores because of the dichotomous character of having encountered aggression

within the past year. Construct validity of the POAS-s and POIS was assessed by an exploratory factor

analysis using principal component analysis (Polit & Beck, 2017). The varimax rotation with Kaiser

normalisation was used. The Kaiser-Meyer-Olkin (KMO) Measure of Sampling Adequacy over 0.50,

Bartlett’s test of sphericity and scree plots were evaluated. A requirement of at least 10 participants per

variable of the POAS-s and POIS was intended (Norman & Streiner, 2014). Internal consistency of the

POAS-s and POIS was studied by calculating inter-item correlations Cronbach’s alpha (Polit & Beck,

2017). Cronbach’s alphas were interpreted as described by Streiner and Norman (2003): 0.70 <

Cronbach’s α < 0.90. To assess stability reliability, intraclass correlation coefficients were calculated for

each item of the POAS-s and POIS (Shrout & Fleiss, 1979). Due to the stable nature of the items of the

SOVES, a reliability assessment did not seem appropriate. Reliability coefficients ≥0.70 were considered

as satisfactory (Polit & Beck, 2017). All statistical analyses were performed using SPSS version 22.0

(SPSS Inc., Chicago, IL, USA)


45

Table 1. Pre-defined groups based on empirically and theoretically expected difference in frequency of

experiencing patient and visitor aggression – Results of the known groups technique.

(Pre-defined) Groups Group A

Expected to encounter more experiences of

patient and visitor

aggression

Group B

Expected to encounter fewer experiences of

patient and visitor

aggression

Significance

X2 e

df f

P g

Having more patient contact time (≥60%) (A) a

vs. having little patient contact time (≤30%) (B) a

83 (85.6)

14 (14.4)

3.941

1

0.047

Younger nurses (A)b vs. older nurses (B)b

47 (64.4)

26 (35.6)

1.162

1

0.281

Bachelor degree (A)c vs. undergraduate degree (B)c

50 (52.6)

45 (47.4)

14.022

1

<0.001

Working with patients ≥65 years (A)d vs. working with patients <65 years (B)d

41 (61.2)

26 (38.8)

11.453

1

<0.001 a Theoretically expected difference b Expected difference based on Adib et al., 2002; Camerino et al., 2008; Estryn-Behar et al., 2008; Farrell et al., 2006; Hahn et

al., 2013; McKenna, Poole, Smith, Coverdale, & Gale, 2003; Shields & Wilkins, 2009; Wei et al., 2016. c Expected difference based on Pai & Lee, 2010; Wei et al., 2016. d Expected difference based on Hahn et al., 2012; Hahn et al., 2013; McKenna et al., 2003; Roche et al., 2010. e Pearson Chi-Square f Degrees of freedom g P-value

3. | Results

3.1. | Phase I: Translation and adaption of the SOVES, POAS-s and POIS

Based on the assessment of the expert panel (stage 1 and 3) and the pilot test (stage 2), no items of

the questionnaire were deleted. The expert panel rated all the items to be relevant and appropriate for

the Belgian context. Three questions on ethnicity and country of birth were added to the SOVES as part

of participants’ demographic characteristics. The expert panel and pilot test suggested changes to the

structure, lay-out and wording to enhance comprehensibility and to allow a more efficient completion of

the questionnaire. Based on these suggestions, items were adapted and moved to other sections. Table

4 (supplementary material) provides some examples of these changes.

3.2. | Phase II: Assessment of psychometric properties of the Dutch version of the

SOVES, POAS-s and POIS

3.2.1. Sample and participants

A total of 238 nurses participated. The overall study response rate was 61.4% (n=238/387). Participants

were predominantly female (92%), had a bachelor degree (60.1%), and the largest age group was

Chapter II

46

between the age of 18 and 29 years (42%). More than half of the nurses (60.5%) stated to have more

than 10 years of professional experience in healthcare, and about 63.8% of the nurses had more than

5 years of experience in their present position. Nurses’ demographic and professional characteristics

are displayed in table 2.

Table 2. Demographic characteristics of the participants.

% (n) % (n)

Gender (female) 92.0 (219) Age Educational level 18-29 42.0 (100)

Diploma degree 32.8 (78) 30-45 34.0 (81) Bachelor degree 60.1 (143) ≥ 46 24.0 (57) Master’s degree 5.0 (12) Professional experience in healthcare (years)

Missing 2.1 (5) 0-4 15.6 (37) Ethnicity 5-9 23.1 (55)

Belgian 98.7 (235) 10-15 20.2 (48) Other 0.9 (2) ≥ 15 40.3 (96) Missing 0.4 (1) Missing 0.8 (2)

Country of birth Professional experience in present position (years)

Belgium 96.6 (230) < 1 11.8 (28) Other 3 (7) 1-4 17.2 (41) Missing 0.4 (1) 5-10 23.5 (56)

Level of employment (%) ≥ 10 40.3 (96) Up to 50 6.3 (15) Missing 7.1 (17) 50-89 41.2 (98) Workplace 90-100 48.3 (115) Medical ward 17.2 (41) Missing 4.2 (10) Intensive care 8.0 (19)

Time spent in direct patient contact (%) Geriatrics 5.5 (13) Up to 30 7.6 (18) Surgery 18.5 (44) 30-59 12.6 (30) Pediatrics 10.5 (25) ≥ 60 76.9 (183) Emergency 0.4 (1) Missing 2.9 (7) Other 25.6 (61)

Missing 14.3 (34)

3.2.2. Psychometric evaluation of the instruments.

Construct validity of the SOVES. Experiences of aggression of pre-defined groups were compared.

Nurses with more direct patient contact (≥60%) proved to have significantly more experiences of

aggression than nurses with fewer direct patient contact (≤30%)( X2 = 3.941, df = 1, P = 0.047). Younger

nurses did not have significantly more experiences of aggression than older nurses ( X2 = 0.340, df = 1,

P = 0.560). Nurses with a diploma degree proved to experience significantly less aggression than nurses

with a bachelor’s degree ( X2 = 14.022, df = 1, P <0.001). Nurses working with patients ≥65 years of age

proved to experience significantly more aggression than nurses working with younger patients ( X2 =

11.453, df = 1, P <0.001) (table 1).

Construct validity of the POAS-s. An exploratory factor analysis was performed. The significance of

Bartlett’s test of sphericity (x2 = 368.5, df = 66, P <0.001) and the size of the KMO measure of sampling

adequacy revealed that factoring was appropriate. The scree plot suggested a two-factor solution with


47

eigenvalues of 2.0. Following factors were identified: factor (1): Aggression as a

dysfunctional/undesirable phenomenon; and factor (2): Aggression as a functional/comprehensible

phenomenon. The two factors accounted for 46.7% of the variance (see table 3 for factor loadings).

Construct validity of the POIS. An exploratory factor analysis was used. The KMO showed sampling

adequacy (KMO = 0.875). Bartlett’s test of sphericity was statistically significant ( x2 = 1093.2, df = 36,

P <0.001), indicating there was justification for the factor analysis. The scree plot showed a two-factor

solution with eigenvalues of 1.0. Following factors were identified: factor (1): Structured interventions,

reflection and evaluation are important to manage aggression; and factor (2): Preventive measures are

important to manage aggression. The two factors accounted for 68.5% of the variance (see table 3 for

factor loadings).

Table 3. Factor analysis using principal component analysis of the shortened Perception of Aggression

Scale (POAS-s), and the perception of importance of intervention skills scale (POIS).

The shortened Perception of Aggression Scale (POAS-s)

No. Item Factor 1 Dysfunctional

Factor 2 Functional

1 Aggression is violent behaviour to others and self 0.801 -0.004 2 Aggression is a conscious battery against someone 0.706 -0.150

3 Aggression is to hurt other mentally or physically 0.596 0.057 4 Aggression is any action of physical violence 0.639 -0.157 5 Aggression is a disturbing intrusion to dominate healthcare staff 0.727 -0.062 6 Aggression is any expression that makes someone else feel unsafe,

threatened or hurt

0.549

-0.174

7 Aggression is emotionally blowing off steam -0.245 0.646

8 Aggression opens new pathways in care and treatment -0.058 0.727

9 Aggression helps the healthcare staff to see the patient from another point of view

0.133

0.710

10 Aggression is an emotion like laughing and crying -0.057 0.563

11 Aggression is an expression of protection of private sphere -0.121 0.472

12 Aggression is the start of a positive staff – patient relationship -0.010 0.758

The perception of importance of intervention skills scale (POIS)

No. Item Factor 1 Structure

Factor 2 Prevention

1 Team interventions 0.793 0.294 2 Safe physical restraints for individuals 0.527 0.384 3 Self-awareness in interactions with patients/clients/family members 0.858 0.188

4 Theories of aggression 0.672 0.308 5 Analysis of the situation with the team 0.839 0.191 6 Follow-up discussions about the situation with patients/clients/family

members

0.737

0.311

7 Identification and assessment of potentially violent individuals 0.245 0.887

8 Verbal interaction/communication with potentially violent individuals 0.233 0.901

9 Setting boundaries/limits with potentially violent individuals 0.512 0.590

Internal consistency of the POAS-s and POIS. For the POAS-s, Cronbach’s alpha was 0.64 for factor

1, and 0.70 for factor 2. For the POIS, Cronbach’s alpha was 0.88 for factor 1; and 0.84 for factor 2.

Chapter II

48

Stability reliability of the POAS-s and POIS. A total of 81 nursing students completed the instruments

twice. The intraclass correlation coefficient for the POAS-s ranged between 0.71 (95% CI = 0.53–0.82,

P <0.001) and 0.88 (95% CI = 0.80–0.93, P <0.001). The intraclass correlation coefficient for the POIS

ranged between 0.81 (95% CI = 0.69–0.88, P <0.001) and 0.93 (95% CI = 0.89–0.96, P <0.001).

4. | Discussion

An accurate assessment of patients’ and/or family members’ aggression in general hospital settings is

an important step in developing and implementing strategies to prevent and manage patients’ and/or

family members’ aggression. The purpose of this study was to translate and evaluate psychometric

properties of three assessment instruments regarding aggression for use in general hospital settings.

These instruments are the Survey of Violence Experienced by Staff (SOVES); the shortened Perception

of Aggression Scale (POAS-s) and the Perception of Importance of Intervention Skills Scale (POIS).

The findings support the validity and reliability of the Dutch version of the three instruments.

Construct validity of the SOVES was assessed by the known-group technique. Different groups of

nurses that were empirically and theoretically expected to encounter more or fewer experiences of

aggression were compared. As expected, nurses who worked with patients over 65 years, nurses who

had more patient contact time ( ≥60%), and nurses with a bachelor’s degree seemed to have significantly

more experiences of patient aggression within the past year in comparison to nurses working with

younger patients, nurses having little patient contact time ( ≤30%), or nurses having a diploma degree.

However, younger nurses did not seem to have significantly more experiences of patient aggression

than older nurses. This finding might partially be explained by the lack of sensitivity in the categorical

group comparison, nurses under the age of 30 were compared to nurses over the age of 46 years.

Nurses’ ages were not assessed as a continuous variable. And as there were only three categories

regarding nurses’ ages ( <30, 30-45, and >46), this division might be too broad to render a significant

difference.

Construct validity of the POAS-s and POIS were assessed in factor analyses. Conform previous studies

(Abderhalden et al., 2002; Needham et al., 2004; Hahn et al., 2011), the data confirmed two-factor

structures in both the POAS-s and POIS. Both two-factor solutions explained 47% and 69% of the

variance respectively. Subsequently, internal consistency in the construct of the POAS-s with a

Cronbach’s alpha of 0.64 for factor 1 (‘aggression perceived as a dysfunctional/undesirable


49

phenomena’) and 0.70 for factor 2 (‘aggression perceived as a functional/comprehensible phenomena’)

appeared to be rather moderate to acceptable. These alpha-values are comparable to those obtained

in other studies (Needham et al., 2004; Hahn et al., 2011). The moderate explained variance and internal

consistency might be ascribed to the complexity of the construct the items of the POAS-s are measuring.

Perceptions of aggression constitute a multidimensional construct. And perceptions are related to the

extent of exposure to aggression experienced, the causes and types of aggression, the perpetrators,

the management of aggression and the severity of injuries sustained (Jansen et al., 2005). This

complexity of the construct of perceptions suggests a multidimensionality of perceiving aggression which

challenges assessment of internal consistency. A comprehensive understanding of perceptions of

aggression might be acquired by integrating the dimensions Jansen et al. (2005) envisioned in the

Attitude of Aggression Scale. This instrument constitutes five dimensions rather than the two-

dimensional POAS-s, and is validated in mental health nurses (Jansen et al., 2005). Further research

could transfer and adapt these dimensions for use in general hospital settings.

Internal consistency in the construct of the POIS was found to be relatively high. A Cronbach’s alpha of

0.88 was found for factor 1 (perceiving structured interventions, reflection and evaluation as important

in managing aggression) and an alpha-value of 0.84 for factor 2 (perceiving preventive measures as

important in managing aggression). These values and the explained variance are higher than the ones

found in the original development and validation study of the POIS (Hahn et al., 2011). Consequently,

the POIS can be considered to be a promising instrument to acquire nurses’ perceptions on the

importance of intervention skills in managing aggression in general hospital settings. Insight into nurses’

perceptions about which skills they address in managing aggression can inspire intervention strategies

to support nurses in managing aggression.

The psychometric assessment supported the test-retest reliability of the instruments as the intraclass

correlations of the POAS-s and POIS reached the established recommendations. However, these

results have to be interpreted with caution because of the short interval between the two administrations.

Besides this limitation, the study was subject to other limitations. The sample comprised 238 nurses,

which can be considered to be rather limited. As the study focused on the psychometric properties of

instruments, and KMO measures in preparation of factor analyses indicated sampling adequacy, this

limited sample proved sufficient. Moreover, ten respondents per item is commonly recommended as a

minimum to support factor analysis (Polit & Beck, 2017).

Chapter II

50

Another limitation pertains the assessment of content validity. As no systematic quantification was

produced, this might be considered to be a limitation. However, various discussions on relevance,

meaning and appropriateness of the content of the instruments were conducted by a diverse researcher

expert panel in the field of aggression in healthcare systems. In these continued discussions, the

consistency of the content of the instruments with literature (f.e. Hahn et al., 2013) was taken into

consideration. This researcher expert panel thoroughly reviewed the translation process. This measure

was taken instead of performing back-translations. In discussing translations and considering technical

and semantic equivalence, and cultural relevance of questions, a good method of cross-cultural

translation and adaption of the instruments was sought (Squires et al., 2013). As no gold standard for

translation techniques exists (Cha, Kim, & Erlen, 2007), the method used in this study can be considered

as valuable because of the agreement that was reached among the expert panel, and the sound

adaptions and rather modest changes that were administered to the instruments. Finally, as validation

of instruments is considered to be a continuous process, further research should obtain a larger sample,

and procure a multidimensional assessment of perceptions of aggression.

4.1. | Implications for nursing management

Patient aggression is a problem for nurses. Consequently, this topic is on the agenda of many hospitals

in many countries. Because of the risk that nurses face, there is an interest to understand the

consequences of experiencing aggression. A number of consequences have been linked to aggression

in healthcare, pointing out how the occurrence of aggression causes harm to individual nurses, quality

of patientcare, and organisations as a whole. Individual nurses are placed at an increased risk of injury,

low morale, sleep disturbances, loss of self-confidence, etc. that compromise the physical and

psychological well-being of nurses (Gerberich et al., 2004; Roche et al., 2010). These consequences

affect caregiving for future patients as research points out how nurses experience a loss of empathy

towards patients, increase avoidance with fewer contacts with patients or adopt passive roles (Needham

et al., 2005). Moreover, patient aggression is associated with falls, medication errors and late

administration of medication, which signifies a striking impact of experiencing patient aggression on the

quality of patientcare (Roche et al., 2010). On an organizational level, organisations are faced with

reduced job motivation (Needham et al. 2005), and increased absenteeism (Foster et al., 2007), and

staff turnover rates (Luckhoff et al., 2013). These consequences are all detrimental especially in current

times of nursing shortage (Estryn-Behar et al., 2008). Gaining an accurate and validated measure of


51

patients’ aggression and/or family members’ aggression allows tailoring of interventions to prevent, and

manage aggression issues in general hospital settings.

5. | Conclusion

An objective measure to study aggression in nursing practice is important. The Survey of Violence

Experienced by Staff, the shortened Perception of Aggression Scale and the Perception of Importance

of Intervention Skills Scale showed acceptable to good psychometric properties. The combination of

these assessment instruments can provide and advance knowledge on manifestations of patients’

and/or family members’ aggression on general hospital wards. This kind of representation can inform

intervention strategies in managing aggression that take into consideration the needs of the specific

setting, the involved patients and the professional caregivers.

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52

Table 4. Supplementary material. Overview of question adaptions of the SOVES, POAS-s and POIS

Questions Remarks Adaptions Stage 1a (n=7)

Stage 2b (n=13)

Stage 3c (n=4)

SOVES – ‘Please indicate whether your post is primarily’

On wording and answers

- Rewording of question - Addition of answers: ‘direct

patient care’; ‘other’ (open-ended question)

X X X

SOVES – ‘Please indicate the patients groups with which you most regularly work’

On answers ‘Babies, children and adolescents (up to 18 years)’ changed to ‘Babies and children (up to 12 years)’ and ‘Adolescents (12-18 years)’

X X

SOVES – ‘Please indicate your current age’

On answers Deletion of ‘up to 17 years’ X X

SOVES – ‘Please indicate the frequency of that verbal aggression within the past year’


- Rewording of question - Frequencies: ‘2-10 times’

changed to ‘2-5 times’ and ‘6-10 times’

X X

SOVES – ‘Using the scale below, place an (X) on the line to show how you would rate the emotional impact of the most recent occurrence of verbal aggression towards you’

On wording, answers and feasibility

- Rewording of question - Ordinal scale changed to

VAS-scale for an analogue and more efficient completion of the questionnaire

X

SOVES – ‘Using the scale below, place an (X) on the line to show how you would rate the emotional impact of the most recent occurrence of a threat towards you’




X

SOVES – ‘Following the most recent occurrence of physical aggression in the workplace, how would you classify any physical injury sustained?’


- Rewording of question - Addition of ‘none’ and

‘other’ (open-ended question)

X X X

SOVES – ‘Using the scale below, place an (X) on the line to show how you would rate the emotional impact of the most recent occurrence of physical aggression towards you’




X

SOVES – ‘Please indicate how occurrences of verbal aggression, threats, or physical aggression in your workplace are formally reported?’

On clarity, wording and answers

- Rewording of question and answers

- Addition of ‘not applicable’; ‘I do not know’ and ‘other’ (open-ended question)

X X

SOVES – ‘Please indicate how often you formally reported occurrences of verbal aggression, threats and physical aggression in your workplace’

On answers Addition of ‘not applicable’ X

SOVES – ‘Was training …’

On answers Addition of ‘other’ (open-ended question)

X X


53

SOVES – ‘Please indicate the training you received’

On answers Addition of ‘other’ (open-ended question)

X X

SOVES – ‘Using the scale below, place an (X) on the line to show how confident you feel using verbal intervention skills in the management of potentially violent situations in your Workplace’

On feasibility Ordinal scale changed to VAS-scale for an analogue and more efficient completion of the questionnaire

X

SOVES – ‘Using the scale below, place an (X) on the line to show how confident you feel using physical interventions skills in the management of potentially violent situations in your workplace’


X

SOVES – ‘Using the scale below, place an (X) on the line to show how necessary you feel training in aggression management is for your current work assignment’


X

SOVES – ‘Does your institution have a formal policy/protocol of support for staff who have been assaulted’


- Rewording of question - Addition: when answering

‘yes’: additional choice: ‘I know the policy’ and ‘I do not know the policy’

X X

SOVES – ‘Please indicate on the scales to the right of the following statements the strength of your agreement or disagreement’ - item 1, 2, 3, 4, 5, 6 and 8

On wording Rewording of question and answer options

X X X

POIS – ‘Please rate each of the skills listed below according to how important you think they are for training in your current workplace (indicate how strongly you agree or disagree by circling a number between 1 – 5 on the scale provided)’


X

POAS-s – Questions 4, 7 and 8

On wording Rewording of question X X X

aStage 1: changes based on the assessment of the expert panel (phase I) bStage 2: changes based on the assessment of the pilot test (phase I) cStage 3: changes based on the assessment of the researcher expert panel (phase I)

Chapter II

54

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Assessment of aggression: validation of instAssessment of aggression: Experiences and perceptions

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Assessment of aggression: validation of instAssessment of aggression: experiences and perceptions

59

Chapter III.

EXPERIENCES AND PERCEPTIONS OF AGGRESSION OF

NURSES WORKING IN PRIMARY CARE AND GENERAL

HOSPITAL SETTINGS

Tina Vandecasteele1,2, Ann Van Hecke1,3, Veerle Duprez1, Dimitri Beeckman1, Sofie Verhaeghe1,2





Based on a manuscript submitted to the Journal of Advanced Nursing, under revision.

Chapter III

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Assessment of aggression: experiences and perceptions

61

Aggression of patients and their family members directed towards nurses: Experiences

and perceptions of nurses working in primary care and general hospital settings

ABSTRACT

Aims. To assess nurses’ experiences of aggression by patients and their family members in primary

care and general hospital settings; and to identify factors associated with nurses’ perceptions of

aggression and its management.

Background. Even though a lot of research focused on nurses’ exposure to aggression, little is known

about nurses working in primary care. Understanding how nurses perceive aggression is important as

perceptions influence strategies used to manage aggression.

Design. Cross-sectional study (September 2014-December 2016).

Methods. Three validated instruments were used (the Survey of Violence Experienced by Staff; the

shortened Perception of Aggression Scale; and the Perception of Importance of Intervention Skills

Scale). The sample comprised 769 nurses from 24 general wards and one primary care organisation.

Descriptive statistics, Chi square and Independent-Samples t-test were performed. Multiple logistic

regression analyses were used to determine factors associated with perceptions of aggression and its

management.

Results. The majority of hospital nurses (89.2%) and primary care nurses (77.9%) indicated to have

experienced aggression. Primary care nurses were more emotionally burdened because of verbal

aggression (p=0.002), threats (p<0.001) and physical aggression (p<0.001) than hospital nurses.

Different factors were associated with perceiving aggression as a dysfunctional or as a functional

phenomenon. More working experience (OR 2.8), having duties in predominantly direct patient care (OR

6.3) or in education (OR 8.0), experiencing threats (OR 10.9) and having contact with patients’ parents

(OR 3.6) were associated with increased odds of perceiving aggression as a dysfunctional phenomenon.

The likelihood to perceive aggression as a functional phenomenon increased when nurses were male

(OR 3.9), worked in primary care (OR 2.4), were fulltime employed (OR 5.1), and had contact with

patients’ parents (OR 9.1) or patients’ partners (2.4).

Conclusion. Aggression is a major problem for nurses, irrespective of work setting. Aggression of

patients’ family members is highly prevalent. This study identified patient-related, nurse-related and

Chapter III

62

work-related characteristics associated with nurses’ perceptions of aggression suggesting crucial points

for developing interventions to support the understanding and management of aggression in nursing

practice. Future research should focus on further exploring the processes at play in perceiving specific

patients’ behaviour or patient’s family member’s behaviour as aggressive.

Key words. Aggression, general hospital, nurses, POAS-s, POIS, primary care, SOVES, violence.


63

1. | Introduction

Aggression in care relationships is internationally acknowledged as a serious problem for nurses

(Camerino et al., 2008), and the reported increase of patient aggression has been of interest to

researchers across countries in recent years (Spector, Zhou, & Che, 2014).

In addressing the problem of aggression in healthcare, research has focused on prevalence (Camerino

et al. 2008; Wei, Chiou, Chien, & Huang, 2016), determinants (Adib et al. 2002; Hahn et al., 2013), risk

factors (Amore et al., 2008; Gillespie, Gates, Miller, & Howard, 2010), and consequences (Sofield &

Salmond, 2003; Wells & Bowers, 2002), contributing to a greater understanding of aggression in care

relationships. On the level of patients’ characteristics (Hahn et al., 2013), staff characteristics (Duxbury,

2002; Jansen, Dassen, & Groot Jebbink, 2005), staff-patient and visitor interactions (Winstanley &

Whittington, 2004; Winstanley, 2005), and organizational characteristics (Farrell, Bobrowski, &

Bobrowski, 2006), different factors have been identified to contribute to the occurrence of patient

aggression. Research also indicates that -when being compared to other caregivers- nurses appear to

be at especial risk to encounter patient aggression due to the nature, duration and intensity of care

relationships with patients (Abderhalden et al., 2007; Camerino et al., 2008; Waschgler et al., 2013).

With regard to nurses’ working contexts, most of the research on aggression relates to geriatric (Almvik,

Rasmussen, & Woods, 2006; Duxbury, Pulsford, Hadi, & Sykes, 2013), emergency (Gerdtz et al., 2013),

and mental health settings (Abderhalden et al., 2007). Few attempts have been made to examine

aggression in general hospital settings (Winstanley & Whittington, 2004; Hahn et al., 2013; Heckemann

et al., 2015). However, research indicates that general hospital settings are increasingly regarded to be

vulnerable for aggressive incidents (Roche, Diers, Duffield, & Catling-Paull, 2010).

Moreover, with regard to nurses’ experiences of aggression in care relationships, surprisingly little is

known about nurses working in primary healthcare or community care. Research on aggression in

primary care generally focuses on patients experiencing domestic violence (Malpass et al. 2014; Pal,

2016), abuse (Williamson et al., 2015), or intimate partner violence (Higgins, Manhire, & Marshall, 2015;

Sawyer, Coles, Williams, & Williams, 2016). Few studies assessed patient aggression against general

practitioners (Magin et al., 2005) or nurses (Geiger-Brown et al. 2007; Da Silva et al., 2015). The few

existing studies focusing on primary care workers agree that aggression is common in primary care,

Chapter III

64

entailing the potential to be very stressful for caregivers (Barling, Rogers, & Kelloway, 2001; Büssing &

Höge, 2004).

Regarding the primary care context, some assumptions can be made about nurses’ work climate which

makes them more prone to experience patient aggression in comparison to hospital nurses. Primary

care nurses often act directly within communities, perform activities outside health centres (such as

private home visits) and generally work alone (Da Silva et al., 2015). The protection that nurses have in

hospital settings (e.g. presence of colleagues, security guards or alarm systems) is not present in

primary care (Geiger-Brown et al., 2007) which implies that nurses have to rely on their own resources

to manage aggression (Barling et al., 2001). This might result in primary care nurses being more

vulnerable to patient aggression than hospital nurses. However, experiences of patient aggression have

not been compared across both nurses’ work settings.

In addition, scarce literature is available about nurses’ perceptions of aggression. Literature has

emphasized nurses’ attitude towards patient aggression to be influential towards intervention strategies

in handling patient aggression (Duxbury, 2002; Vandecasteele et al., 2015). This link is acknowledged

in the Theory of Reasoned Action (Fishbein & Ajzen, 1975). Nurses’ perceptions about causation of

aggression may influence their approach to manage incidents (Jansen et al., 2005; Duxbury, Hahn,

Needham, & Pulsford, 2008). Research on perceptions of aggression primarily focused on nurses

working in mental health settings (Needham et al., 2005; Verhaeghe et al., 2016), in emergency settings

(Morken, Alsaker, & Johansen, 2016), or in residential care settings when caring for patients with

dementia (Duxbury, Pulsford, Hadi, & Sykes, 2012). However, generalizing results from these settings

to a more general setting of primary healthcare or general hospital wards is difficult. To our knowledge,

there is no literature focusing on nurses’ perceptions of patient aggression when working in a general

hospital setting, or in primary healthcare. We can assume these nurses, especially nurses in primary

healthcare, perceive patient aggression in a different way than nurses working in other contexts. They

generally know patients for a longer time as they contribute to continuity of care (Griffiths, Maben, &

Murrell, 2011), they guide patients in their daily living (Fletcher & Dahl, 2013), and get acquainted with

contextual factors which might explain patients’ behaviour.


65

2. | The study

2.1. | Aims

This study aims:

To compare nurses’ experiences of patient aggression and aggression by patients’ family

members in both primary care and general hospital settings.

To identify associations between patient-related, nurse-related and work-related characteristics

and nurses’ perceptions about (the management of) aggression.

2.2. | Design

A cross-sectional study was conducted.

2.3. | Participants

Data were collected in three general hospitals, a University hospital and a primary care organization in

Belgium between September 2014 and December 2016. In the hospital settings, all nursing officers

were invited to be involved in this study. Twenty-four general wards were invited to participate.

Emergency, geriatric and mental health departments were excluded. Each nurse manager, head of

department and head nurse was informed and invited to include their ward. All twenty-four wards

participated. Nurses working on these wards were invited to take part. The researchers informed the

nurses through a short presentation during team meetings. To ensure anonymity, completed

questionnaires were returned in secured boxes on the ward. The researchers collected these once a

week, returning to each ward to provide reminders and maximize participation.

In the primary care context, two departments of one primary care organization were included. In

Belgium, nurses who work in primary care are most often part of a larger primary care organization

which mainly involves nursing care during home visits. These nurses work in close collaboration with

general practitioners and other professional caregivers, but they are not necessarily directly employed

in general practice. Nurse officers of both departments were informed about the study, and invited to

participate.

In one of the departments, a convenience sample was recruited. Nurses were informed about the study

through a short video on the website of this department, and were able to complete the questionnaire

through a web-based link. In the second department, data were collected in 300 randomly selected

nurses. The nurse officer provided an anonymous list of all nurses. A random sample generated by

Chapter III

66

SPSS version 22.0 was obtained from this list. These nurses were informed about the study and invited

to participate through a short video which was sent via e-mail. Through a web-based link, nurses could

anonymously answer the questionnaire. Reminders were sent via e-mail, and were provided once every

two weeks between November to December 2016.

2.4. | Data collection

Nurses’ experiences and perceptions regarding patient aggression and aggression of patients’ family

members were assessed using three instruments.

The Survey of Violence experienced by Staff (SOVES). The SOVES was originally developed by

McKenna (2003) to gather information on workplace aggression, and to acquire data on involved

healthcare staff, patients and the broader workplace environment. The SOVES explores five themes:

(1) prevalence of aggression, (2) consequences of aggression, (3) reporting of aggression, (4) support

after experiencing aggression, and (5) training in managing aggression; as each of these themes is

related to three manifestations of aggression: verbal aggression, threats and physical aggression.

‘Verbal aggression’ is understood as abusive or offensive language, personally derogatory remarks,

profanity or obscene comments. ‘Threats’ are explained as warnings of intent to injure, harassment,

physical intimidation or threat with a weapon. ‘Physical aggression’ comprises slapping, pinching,

pushing, shoving, spitting, kicking or the use of a weapon. The SOVES provides a comprehensive

representation of aggression as several variables (nurses’ characteristics, patients’ characteristics,

nurses’ experiences of different types of aggression, practice characteristics and broader organizational

characteristics) are assessed. Close-ended questions and Visual Analogue Scales (VAS) are used to

assess these variables. Content validity and internal consistency have been assessed by McKenna

(2004), while feasibility and face validity of the German version of the SOVES have been appraised by

Hahn et al. (2011), showing good psychometric properties. The SOVES was translated into Dutch and

tested for use in the Belgian general hospital setting in a sample of 237 nurses. Face validity, content

validity and construct validity have been assessed showing acceptable to good psychometric properties

(Vandecasteele et al., (2017) - Submitted manuscript). Limited adjustments on sociodemographic

characteristics were made to suit the use in a primary care context.

The shortened Perception of Aggression Scale (POAS-s). The POAS, originally developed by

Jansen, Dassen, & Moorer (1997), consisted of 30 Likert-scaled statements which express various

views regarding aggression. In 2004, Needham et al. derived a shortened version, the POAS-s,


67

consisting of 12 items on a 5-point Likert scale, encompassing two dimensions in perceiving aggression:

aggression as a more dysfunctional and undesirable phenomenon (dimension 1) or as a more functional

and comprehensible phenomenon (dimension 2). Validation of the POAS-s has been assessed through

construct validity (Abderhalden et al., 2002), test-retest reliability, internal consistency (Needham et al.,

2004; Hahn et al., 2011), and content validity (Hahn et al., 2011), providing satisfactory psychometric

properties. The Dutch version of the POAS-s appraised construct validity and internal consistency,

procuring acceptable psychometric properties (Vandecasteele et al., (2017) - Submitted manuscript).

The Perception of Importance of Intervention Skills Scale (POIS). The POIS was developed by

Hahn et al. (2011) to measure perceptions of the importance of intervention skills in managing patient

aggression in a general hospital setting. The instrument consists of nine items reflecting common

prevention and intervention strategies (e.g. verbal communications, setting limits, intervening as a

team), measured on a 10-point VAS-scale. In 2011, a psychometric evaluation was conducted in

assessing internal consistency and construct validity in general hospital settings (Hahn et al., 2011),

emphasizing two dimensions in perceptions about aggression management: structured interventions,

evaluation and reflection to manage aggression (dimension 1), and preventive measures to manage

aggression (dimension 2). Good psychometric properties of the Dutch version were obtained in

assessing construct validity and internal consistency (Vandecasteele et al., (2017) - Submitted

manuscript).

2.5. | Data analysis

Frequencies were determined to describe participants’ demographic and professional characteristics.

Chi-square and Independent-Samples t-tests were used to test for differences among the two samples

regarding experiences of patient aggression and aggression caused by patients’ family members, and

different factors related to aggression (e.g. training in managing aggression). Chi-square tests were

used for categorical variables (e.g. utilized support mechanism following an occurrence of aggression),

while t-tests were used for continuous variables (e.g. emotional impact of verbal/physical aggression or

threats).

Logistic regression models were used to investigate factors associated with nurses’ perceptions of

aggression and its management. Multiple regression models were run with the two dimensions of the

POAS-s (‘perceiving aggression as a dysfunctional and undesirable phenomenon’ and ‘perceiving

aggression as a functional and comprehensible phenomenon’) and the two dimensions of the POIS

Chapter III

68

(‘perceiving structured interventions/reflection as important to manage aggression’ and ‘perceiving

preventive measures as important’) as dependent variables. Dependent variables were dichotomized.

A mean score on the statements constituting e.g. the perception that aggression is a

dysfunctional/undesirable phenomenon was computed per participant. Subsequently, mean scores

were categorized as ‘do not agree’ (range [1-2.4] = 0) and ‘agree’ (range [3.6-5] = 1). Neutral scores,

referring to an undecided opinion whether or not one agreed with e.g. the perception that aggression is

a dysfunctional phenomenon, were removed from analysis. Independent variables were selected based

on (1) a p<0.10 between the independent and dependent variable in univariate analyses, (2) an

empirically expected relationship between the independent and dependent variable based on literature,

or (3) a theoretical and logically expected relationship between the independent and dependent variable.

All independent variables were dichotomized. Independent variables were presented as odds ratios

(OR) with 95% confidence intervals. The significance level was held at α <0.05. Previous to regression

modelling, interrelation among independent variables was explored using Chi-square tests. All statistical

analyses were performed using SPSS version 22.0 (SPSS Inc., Chicago, IL, USA).

2.6. | Ethical considerations

The study was approved by the Ethical Committee of the Ghent University Hospital (B/670201421265)

and the Ethical Committees of the participating hospitals. The Institutional Review Board of the primary

care organization approved the study. Participation was voluntary. Hospital nurses provided consent by

signing an informed consent. Primary care nurses consented by completing the questionnaire.

3. | Results

The study population included 769 nurses (hospital setting: 271 nurses and primary care setting: 498

nurses). Response rate was 55% for the sample of hospital nurses, 55.3% and 27.8% for the sample of

nurses working in the two departments of primary care. Participants were predominantly female (94.6%),

had a diploma degree (50%), worked less than fulltime (56.9%) and the largest age group was older

than 46 years (43.5%). More than half of the nurses (76.3% and 72.6%) stated to have more than 10

years of professional experience in healthcare and more than 10 years of professional experience in

their present position. Nurses’ demographic and professional characteristics are displayed in table 1.

Several significant demographic and professional differences were observed among the two samples.

Primary care nurses are characterized by a high percentage of older nurses with a diploma degree, who


69

are less than fulltime employed in practice. Hospital nurses are characterized by a high percentage of

younger nurses with a bachelor (RN) degree. Both samples of nurses had a lot of experience in

healthcare, and spent a lot of time in direct contact with patients.

Table 1. Nurses’ demographic and professional characteristics.

Nurses working in general hospital setting

(N=271 nurses) N (%)

Nurses working in primary healthcare


P-value

Gender 0.008 Male 22 (3.1) 16 (2.3)

Female 247 (34.6) 428 (60.0) Missing 2 54

Age (years) <0.001 18-29 90 (12.6) 70 (9.8)

30-45 95 (13.3) 149 (20.8) ≥ 46 86 (12.0) 225 (31.5) Missing 0 54

Educational level <0.001 Diploma degreea 84 (11.8) 272 (38.2)

Bachelor degree 168 (23.6) 155 (21.8) Master’s degree 16 (2.2) 17 (2.4) Missing 3 54

Professional experience in healthcare (years) <0.001 < 10 years 87 (12.2) 82 (11.5)

≥ 10 years 182 (25.6) 361 (50.7) Missing 3 54

Professional experience in present position (years) 0.908 < 10 years 73 (10.3) 121 (17.1)

≥ 10 years 191 (27.0) 323 (45.6) Missing 6 55

Workplace Medical ward 84 (31.0)

NA*

Intensive care 12 (4.4) Surgery 73 (26.9) Paediatrics 26 (9.6) Other 47 (17.4) Missing 29 (10.7)

Level of employment (%) <0.001 Up to 50 6 (0.8) 34 (4.8)

50-89 110 (15.5) 254 (35.8) 90-100 150 (21.2) 155 (21.9) Missing 5 55

Time spent in direct patient contact (%) <0.001 Up to 30 25 (3.5) 12 (1.7)

30-59 49 (6.9) 49 (6.9) ≥ 60 195 (27.4) 382 (53.6) Missing 2 55

aDiploma degree = Professional degree post-secondary education; *NA= not applicable.

3.1. | Comparison of nurses’ experiences and perceptions of patient aggression and

aggression by patients’ family members in primary care and general hospital setting

Experiences of patient aggression and aggression of patients’ family members were compared across

both settings (table 2). Perceptions regarding aggression and its management are displayed in table 3.

Chapter III

70

Prevalence of patient aggression and aggression of patients’ family members. About 89.2% of

hospital nurses and 77.9% of primary care nurses experienced aggression during their professional

nursing career. Of this group, 62.8% of hospital nurses and 54.1% of primary care nurses experienced

aggression during the past 12 months. Of these hospital nurses, 94,1% had experienced verbal

aggression, 45.3% had experienced physical aggression and 36.1% had experienced threats. In

comparison, 91.9% of primary care nurses indicated to have experienced verbal aggression, 29%

experienced physical aggression and threats were experienced by 40% in the past 12 months. Hospital

nurses experienced more aggression during the past 12 months (p=0.044), and more verbal aggression

of patients or their family members than primary care nurses (p=0.012). More than half (69.0%) of

primary care nurses were exposed to verbal aggression of patients’ family members once, whereas

32.9% of hospital nurses experienced verbal aggression by patients’ family members once.

Consequences of patient aggression and aggression of patients’ family members. Eight primary

care nurses, and two hospital nurses had to take time off duty due to an aggressive incident. Primary

care nurses were more emotionally burdened because of verbal aggression (p=0.002), threats (p<0.001)

and physical aggression (p<0.001) in comparison to hospital nurses.

Support mechanisms used following experiences of aggression. No differences were observed

regarding support mechanisms (e.g. discussions with supervisors, colleagues, partners, friends or

family) following aggressive incidents. The majority of nurses across both samples gained support by

discussing the incident with their colleagues.

Training in the management of aggression. No differences were observed in the number of nurses

following training in aggression management (p=0.297). However, primary care nurses perceived

training as more important than hospital nurses (p<0.001). Primary care nurses appeared to have more

training in identifying and assessing potentially violent individuals (p=0.017), analysing situations within

the team (p=0.003), setting boundaries with potentially violent individuals (p<0.001), being self-aware in

interactions with patients (p=0.015), and having follow-up discussions about situations with patients

(p=0.003). Primary care nurses indicated to be more confident in using verbal (p<0.001) and physical

(p<0.001) intervention skills in managing aggression in comparison to hospital nurses.

Reporting of aggression. More hospital nurses indicated not to report aggressive incidents to

supervisors or line managers in comparison to primary care nurses (p<0.001). More primary care nurses


71

indicated to report ‘almost all to all’ incidents in comparison to hospital nurses (p=0.035). However,

irrespective of work setting, the majority of nurses indicated to report none to a few of the aggressive

incidents they encountered in the past 12 months.

Perceptions regarding aggression and its management. Overall and irrespective of work setting,

nurses were more inclined to agree that aggression is a dysfunctional phenomenon in comparison to

perceiving aggression as a functional/comprehensible phenomenon (table 3). No differences among the

two samples were observed related to perceiving aggression as a dysfunctional phenomenon (p=0.983),

nor as a functional phenomenon (p=0.149). However, primary care nurses perceived both intervention

(p<0.001) and preventive (p<0.001) strategies as more important to manage aggression than the

hospital nurses.

Chapter III

72

Table 2. Comparison of nurses’ experiences regarding patient aggression and aggression of patients’

family members.

Overall irrespective

of setting (N=769 nurses) N (%)

Nurses working in

general hospital setting (N=271 nurses) N (%)

Nurses working in

primary healthcare


X2 (df)

P-value

Experiences of all forms of aggression during the professional careera

630 (81.9)a

242 (89.2)a

388 (77.9)a

0.240 (1)

0.626

Experiences of all forms of aggression during the past 12 monthsb

362 (57.5)b

152 (62.8)b

210 (54.1)b

4.052 (1)

0.044

Experiences of verbal aggression during the past 12 monthsc

336 (92.8)c

143 (94.1)c

193 (91.9)c

8.922 (2)

0.012

Experiences of verbal aggression caused by patientsc

Once 88 (24.3)c 31 (20.4)c 57 (27.1)c 2.202 (2)

0.381 2-5 times 167 (46.1)c 67 (44.1)c 100 (47.6)c

>5 times 67 (18.5)c 31 (20.4)c 36 (17.1)c Experiences of verbal aggression caused by patients’ family membersc

Once 195 (53.9)c 50 (32.9)c 145 (69.0)c 38.321

(2)

<0.001 2-5 times 94 (25.9)c 55 (36.2)c 39 (18.6)c

>5 times 24 (6.6)c 16 (10.5)c 8 (3.8)c Experiences of physical aggression during the past 12 monthsc

130 (35.9)c

69 (45.3)c

61 (29.0)c

10.238(1)

0.118

Experiences of physical aggression caused by patientsc

Once 47 (12.9)c 24 (15.8)c 23 (10.9)c 5.522 (2)

0.063 2-5 times 60 (16.6)c 38 (25.0)c 22 (10.5)c

>5 times 25 (6.9)c 9 (5.9)c 16 (7.6)c Experiences of physical aggression caused by patients’ family membersc

Once 65 (17.9)c 10 (6.6)c 55 (26.2)c 0.882 (2)

0.643 2-5 times 3 (0.8)c 1 (0.7)c 2 (0.9)c

>5 times 1 (0.3)c 0 (0)c 1 (0.5)c Experiences of threats during the past 12 monthsc

139 (38.4)c

55 (36.1)c

84 (40.0)c

0.543 (1)

0.461

Experiences threats caused by patientsc

Once 55 (15.2)c 20 (13.2)c 35 (16.7)c 2.194 (2)

0.533 2-5 times 64 (17.7)c 26 (17.1)c 38 (18.1)c

>5 times 16 (4.4)c 5 (3.3)c 11 (5.2)c Experiences threats caused by patients’ family membersc

Once 83 (22.9)c 22 (14.5)c 61 (29.0)c 1.863 (2)

0.394 2-5 times 28 (7.7)c 11 (7.2)c 17 (8.1)c

>5 times 5 (1.4)c 2 (1.3)c 3 (1.4)c Having to take time off duty due to aggressionc

Yes 10 (2.8)c 2 (1.3)c 8 (3.8)c NP NP

Missing 15 (4.1)c 2 (1.3)c 13 (6.2)c Used support mechanismsc

Discussed with supervisor/ line manager

Yes 117 (32.3)c 41 (26.9)c 76 (36.2)c 2.300(1)

0.129 No 237 (65.5)c 103 (67.8)c 134 (63.8)c

Missing 8 (2.2)c 8 (5.3)c 0 (0.0)c

Discussed incident with a colleague

Yes 237 (65.5)c 94 (61.8)c 143 (68.1)c 0.306(1)

0.580 No 117 (32.3)c 50 (32.9)c 67 (31.9)c

Missing 8 (2.2)c 8 (5.3)c 0 (0.0)c

Discussed incident with a close friend

Yes 47 (12.9)c 16 (10.5)c 31 (14.8)c 0.989(1)

0.320 No 307 (84.8)c 128 (84.2)c 179 (85.2)c

Missing 8 (2.2)c 8 (5.3)c 0 (0.0)c


73

Discussed incident with partner/family member

Yes 117 (32.3)c 51 (33.6)c 66 (31.4)c 0.614(1)

0.433 No 237 (65.5)c 93 (61.2)c 144 (68.6)c

Missing 8 (2.2)c 8 (5.3)c 0 (0.0)c Training in aggression managementa

Yes 181 (23.5)a 69 (25.5)a 112 (22.5)a 2.431(2)

0.297 No 481 (62.5)a 199 (73.4)a 282 (56.6)a

Missing 107 (13.9)a 3 (1.1)a 104 (20.8)a Commonly used structures to formally report aggression incidentsc

Reporting with supervisor (orally)

Yes 215 (59.3)c 109 (71.7)c 106 (50.5)c 27.606(1)

<0.001 No 134 (37.0)c 30 (19.7)c 104 (49.5)c

Missing 13 (3.6)c 13 (8.6)c 0 (0.0)c

Reporting in a specific way (e.g. a protocol)

Yes 82 (22.7)c 33 (21.7)c 49 (23.3)c 0.008(1)

0.930 No 267 (73.8)c 106 (69.7)c 161 (76.7)c

Missing 13 (3.6)c 13 (8.6)c 0 (0.0)c

Reporting in the patient’s files (written)

Yes 256 (70.7)c 104 (68.4)c 152 (72.3)c 1.895(2)

0.388 No 92 (25.4)c 35 (23.0)c 58 (27.6)c

Missing 13 (3.6)c 13 (8.6)c 0 (0.0)c Presence of a formal reporting systemc

Yes 193 (53.3)c 75 (49.3)c 118 (56.2)c 1.211(2)

0.546 No 22 (6.1)c 8 (5.3)c 14 (6.7)c

No idea 114 (31.5)c 51 (33.6)c 63 (0.3)c

Missing 33 (9.1)c 18 (11.8)c 15 (7.1)c Frequency of formally reporting incidentsc

None to a few of the incidents reported

152 (41.9)c

71 (46.7)c

81 (38.6)c

8.632(3)

0.035 Approximately half of the incidents reported

39 (10.8)c

21 (13.8)c

18 (8.6)c

Almost all to all incidents reported 97 (26.8)c 30 (19.7)c 67 (31.9)c

Missing 74 (20.4)c 30 (19.7)c 44 (20.9)c

Mean (SD) Mean (SD) Mean (SD) t (df) p-value

Perceived confidence in managing verbal intervention skillsa

5.42 (2.17)a

4.87 (2.18)a

5.87 (2.09)a

-5.172 (604)

<0.001

Perceived confidence in managing physical intervention skillsa

4.09 (2.47)a

3.59 (2.41)a

4.42 (2.46)a

-3.914 (561)

<0.001

Perceived importance of training in aggression managementa

7.16 (2.06)a

6.50 (2.26)a

7.59 (1.80)a

-6.340 (435.696)

<0.001

Emotional impact of the most recent occurrence of verbal aggressionc

5.09 (2.73)c

4.72 (2.59)c

7.87 (1.64)c

-3.313 (54)

0.002

Emotional impact of the most recent occurrence of physical aggressionc

4.31 (2.92)c

3.55 (2.69)c

4.98 (2.87)c

-4.240 (284)

<0.001

Emotional impact of the most recent occurrence of a threatc

3.86 (2.97)c

3.23 (2.75)c

7.50 (1.31)c

-6.751 (21.532)

<0.001

NP= Not possible due to small sample size, aComparison in relation to the total sample of nurses working in the general hospital

setting or primary care, bComparison in relation to the number of nurses who experienced aggression during their professional career, cComparison in relation to the number of nurses who experienced aggression in the past 12 months, dComparison in

relation to the number of nurses who had training in aggression management. Statistical significant P-values at the 0.05 level are in bold.

Chapter III

74

Table 3. Comparison of nurses’ perceptions regarding aggression and its management.

Overall irrespective

of setting (N=769 nurses)

Nurses working in

general hospital setting (N=271 nurses)

Nurses working in

primary healthcare

(N=498 nurses)

Mean (SD) Mean (SD) Mean (SD) t (df) p-value

Perceptions of aggression (POAS-s)a:

Aggression is a dysfunctional phenomenon (subscale 1 – POAS-s)a,

3.32 (0.654) 3.32 (0.632) 3.32 (0.668) -0.022 (630)

0.983

Aggression is violent behaviour to others and self

4.11 (1.010) 4.14 (0.924) 4.09 (1.063) 0.618 (646)

0.537

Aggression is a conscious battery against someone

2.94 (1.110) 2.81 (1.118) 3.01 (1.098) -2.221 (645)

0.027

Aggression is to hurt other mentally or physically

3.80 (1.082) 3.71 (1.093) 3.86 (1.073) -1.683 (642)

0.093

Aggression is any action of physical violence

2.73 (1.244) 2.88 (1.217) 2.63 (1.253) 2.556 (645)

0.011

Aggression is a disturbing intrusion to

dominate healthcare staff 2.87 (1.138) 2.83 (1.058) 2.89 (1.188) -0.666

(640) 0.506

Aggression is any expression that makes

someone else feel unsafe, threatened or hurt

3.52 (1.063) 3.59 (0.975) 3.48 (1.115) 1.299 (580)

0.195

Aggression is a functional phenomenon (subscale 2 – POAS-s)a

2.30 (0.683) 2.25 (0.631) 2.33 (0.713) -1.445 (564)

0.149

Aggression is emotionally blowing off

steam 3.30 (1.219) 3.20 (1.195) 3.36 (1.232) -1.648

(646) 0.100

Aggression opens new pathways in care

and treatment 1.68 (1.010) 1.68 (0.987) 1.69 (1.026) -0.106

(646) 0.916

Aggression helps the healthcare staff to

see the patient from another point of view 2.10 (1.075) 2.05 (0.987) 2.14 (1.128) -0.992

(585) 0.322

Aggression is an emotion like laughing and crying

2.73 (1.255) 2.66 (1.178) 2.78 (1.301) -1.139 (642)

0.255

Aggression is an expression of protection of private sphere

2.58 (1.044) 2.54 (0.987) 2.61 (1.079) -0.847 (642)

0.397

Aggression is the start of a positive staff – patient relationship

1.43 (0.772) 1.43 (0.774) 1.43 (0.771) -0.027 (640)

0.979

Perceptions regarding the management of aggression (POIS)a

Perceiving intervention strategies as important (subscale 1 – POIS)a

7.721 (1.498)

7.205 (1.513)

8.034 (1.404)

-6.900 (624)

<0.001

Team interventions 7.802 (1.899)

7.478 (1.802)

8.005 (1.930)

-3.441 (635)

0.001

Safe physical restraints for individuals 7.819 (1.867)

7.423 (1.936)

8.061 (1.783)

-4.227 (631)

<0.001

Self-awareness in interactions with

patients/clients/family members 7.730

(1.774) 7.174

(1.806) 8.074

(1.665) -6.412 (634)

<0.001

Theories of aggression 7.012 (2.198)

6.304 (2.260)

7.463 (2.040)

-6.634 (636)

<0.001

Analysis of the situation with the team 7.904 (1.776)

7.298 (1.822)

8.285 (1.638)

-7.099 (638)

<0.001

Follow-up discussions about the situation

with patients/family members 8.028

(1.701) 7.552

(1.773) 8.326

(1.584) -5.590 (476)

<0.001

Perceiving preventive strategies as important (subscale 2 – POIS)a

8.221 (1.339)

7.804 (1.325)

8.484 (1.282)

-6.447 (638)

<0.001

Identification and assessment of potentially violent individuals

8.008 (1.535)

7.626 (1.550)

8.249 (1.477)

-5.102 (639)

<0.001

Verbal interaction/communication with potentially violent individuals

8.268 (1.141)

7.981 (1.141)

8.450 (1.377)

-4.163 (640)

<0.001

Setting boundaries/limits with potentially

violent individuals 8.390

(1.497)

7.815 (1.522)

8.753

(1.361)

-8.116 (639)

<0.001

aComparison in relation to the total sample of nurses working in the general hospital setting or primary care


75

3.2. | Identifying associations between nurses’ characteristics and perceptions

regarding aggression and its management

Statistical modelling. Independent variables were:

Nurses’ characteristics: demographic (gender) and professional characteristics (work setting,

educational degree, level of employment, job experience, training level in aggression

management, perceived importance of training in aggression management, perceived

confidence in managing verbal or physical intervention skills in managing aggression)

Nurses’ accounts of experiences of patient aggression or family members’ aggression:

prevalence (having encountered different forms of aggression during the past 12 months

perpetuated by patients or their family members), consequences (taking time of duty due to

aggressive incidents, emotional impact of verbal or physical aggression or threats, …), reporting

(frequency of formally reporting aggressive incidents), support mechanism following an

aggressive incident (discussion with supervisor, colleague, friend or family), and perceptions

regarding aggression and its management.

Patients’ characteristics and family members’ characteristics: patients’ ages, frequency of

contact with patients’ family members.

Practice characteristics: direct patient contact time, nurses’ primary tasks.

Organizational characteristics: reporting systems regarding experiences of aggression,

commonly used systems to report aggression.

Univariate analyses examined relationships between independent and dependent variables (table 4,

additional files). Multiple regression analyses were run to identify associations between independent

variables and different perceptions regarding aggression and its management (table 5).

Factors associated with perceiving aggression as a dysfunctional and undesirable phenomenon.

Nurses with more experience in their current position had a higher chance to perceive aggression as

dysfunctional than nurses with less experience in their current position (p=0.006). When nurses mostly

work with patients’ parents (p=0.022), or they are mostly involved in direct patient care (p=0.046), or in

the education of nursing students (p=0.032), these factors increased the estimated odds of perceiving

aggression as dysfunctional. Nurses who had experienced threats in the past 12 months were more

likely to perceive aggression as dysfunctional (p=0.021). However, if nurses gained support following

an aggressive incident by discussing the incident with their supervisor, the likelihood to perceive

Chapter III

76

aggression as dysfunctional decreased (p=0.026). The likelihood to perceive aggression as

dysfunctional also decreased with nurses who primarily work with patients over 65 years of age

(p=0.031).

Factors associated with perceiving aggression as a functional and comprehensible

phenomenon. Male nurses had higher estimated odds to perceive aggression as functional than

female nurses (p=0.038). Primary care nurses (p=0.034), and nurses who work fulltime (p=0.048) had

a higher chance to perceive aggression as functional in comparison to hospital nurses or nurses holding

less than a fulltime employment. Nurses who mainly have contact with patients’ partners (p=0.037) or

patients’ parents (p=0.013) had a higher chance to perceive aggression as comprehensible. In contrast,

predominantly caring for patients over 65 years of age decreased the estimated chance to perceive

aggression as comprehensible (p=0.041). The likelihood to perceive aggression as functional decreased

when the commonly used system to report aggression was the verbal report with the supervisor

(p=0.045).

Factors associated with perceiving structured intervention strategies, evaluation and reflection

as important. Nurses with training in aggression management (p=0.007) and nurses with their primary

task in education of nursing students (p=0.017) had an increased estimated chance to perceive

structured interventions, evaluation or reflection as important.

Factors associated with perceiving preventive strategies as important. A logistic regression

analysis was not applicable due to a lack of variance in this dependent variable, and therefore these

results are not displayed in table 5. Two nurses (0.2%) perceived preventive measures as ‘not to

moderately important’, and 162 nurses (21.1%) indicated to be rather neutral regarding the importance

of preventive measures. Whereas, the majority of nurses (n=605, 78.7%) perceived preventive

measures to manage aggression as ‘important to very important’.


77

Table 5. Associated factors of particular perceptions regarding aggression and its management.

Elements

Perceptions of aggression

Perception of the management of

aggression

Perceiving aggression as

a dysfunctional phenomenon

Perceiving

aggression as a functional

phenomenon

Perceiving

intervention strategies as

important

OR (CI 95%)°

P-value

OR (CI 95%)°

P-

value

OR (CI 95%)°

P-value

Gender

Female* Male

0.022 (0.002 – 1.300)

.053

3.876 (1.075 – 13.975)

.038

0.149 (0.006 – 3.946)

.225

Work setting

Hospital setting* Primary setting

2.413 (0.552 – 10.540)

.242

2.397 (1.070 – 5.372)

.034

21.970

(0.583 – 82.502)

.095

Educational degree

Diploma degree* Bachelor degree

0.824 (0.437 – 1.553)

.549

0.674 (0.159 – 2.850)

.591

3.414 (0.163 – 7.307)

.428

Level of employment

No fulltime* Fulltime

0.423 (0.038 – 4.688)

.483

5.127

(1.013 – 25.969)

.048

5.717 (0.216 – 15.023)

.297

Job experience in current position

< 10 years* ≥ 10 years

2.797 (1.336 – 5.863)

.006

0.063 (0.003 – 1.510)

.088

8.935 (0.586 – 17.045)

.115

Training in aggression management

Yes No*

2.375 (0.281 – 20.053)

.427

0.072 (0.004 – 1.328)

.077

2.724 (1.321 – 5.651)

.007

Perceived importance of training in

aggression management Not to moderately important*

Important to very important

NA

NA

6.242 (0.001

– 614.047)

.486

39.688 (0.694 –

20.952)

.075

Perceived confidence in managing verbal intervention skills

Not to moderate confidence*

Confident to very confident

0.076 (0.001 –

8.967)

.289

0.513 (0.075

– 3.501)

.496

NA

NA

Perceived confidence in managing physical intervention skills

Not to moderate confidence* Confident to very confident

0.102 (0.013 – 0.918)

.089

0.111 (0.003 – 4.255)

.238

2.537 (0.281 – 22.898)

.407

Having encountered aggression in

the professional career as a nurse Yes

No*

2.282 (0.797 –

6.535)

.124

0.922 (0.343

– 2.479)

.872

1.308 (0.070

– 24.555)

.858

Having encountered verbal aggression in the past 12 months

Yes No*

1.632 (0.712 – 3.725)

.247

0.151 (0.002 – 72.188)

.548

18.177

(0.168 – 19.558)

.225

Having encountered threats in the

past 12 months Yes

No*

10.902 (1.978

– 60.098)

.021

1.423 (0.552

– 3.666)

.465

1.550 (0.063

– 37.844)

.788

Having encountered physical aggression in the past 12 months

Yes

No*

0.600 (0.248 –

1.449)

.256

1.098 (0.232

– 5.192)

.906

1.784 (0.056

– 57.132)

.743

Frequency of formally reporting aggressive incidents

None to little* Almost half

Almost all

0.246 (0.067 – 0.906)

.056 0.332 (0.041 – 2.707)

.303 NR NR

0.440 (0.138 –

1.395)

.163 0.795 (0.261

– 2.426)

.687 NR NR

Support following aggression: discussion with supervisor

Yes No*

0.018 (0.001 -0.622)

.026

0.392 (0.041 – 3.716)

.414

1.604 (0.073 – 35.077)

.764

Support following aggression:

discussion with partner Yes

No*

1.112 (0.105 –

11.740)

.929

0.912 (0.120

– 6.950)

.929

NA

NA

Support following aggression: discussion with friend/family

Yes

9.761 (0.335 –

284.581)

.185

2.392 (0.292

– 19.588)

.416

NA

NA

Chapter III

78

No*

Support following aggression: discussion with colleague

Yes No*

16.441 (0.839 –322.238)

.065

1.520 (0.247 – 9.360)

.652

0.156 (0.005 – 4.896)

.291

Perceiving aggression as a

dysfunctional phenomenon No agreeing*

Agreed

NR

NR

NR

NR

1.463 (0.160

– 13.423)

.736

Patients’ age: up to 12 years Yes

No*

0.007 (0.001 –

58.481)

.284

0.484 (0.031

– 7.605)

.606

0.839 (0.022

– 31.535)

.925

Patients’ age: 12-18 years Yes

No*

12.575 (0.139

– 1133.541)

.270

0.450 (0.033

– 6.222)

.551

NA

NA

Patients’ age: up to 65 years

Yes No*

0.005 (0.003 – 11.913)

.184

0.046 (0.002 – 1.284)

.070

0.711 (0.025 – 20.539)

.842

Patients’ age: over 65 years

Yes No*

0.261 (0.052 – 0.870)

.031

0.006 (0.003 – 0.807)

.041

1.547 (0.075 – 32.090)

.778

Contact with family members:

mostly husband/wife/partner Yes

No*

NA

NA

2.410 (1.208

– 53.642)

.037

0.506 (0.002

– 2.217)

.975

Contact with family members: mostly parents

Yes No*

3.610 (1.201 – 10.847)

.022

9.121 (1.583 – 52.556)

.013

0.589 (0.034 – 10.317)

.717

Contact with family members:

mostly children Yes

No*

2.687 (0.261-

27.616)

.406

0.432 (0.092

– 2.028)

.288

26.509 (0.556 –

12.211)

.096

% direct patient contact time < 60%*

> 60%

6.342 (0.383 –

51.446)

.054

2.821 (0.352

– 22.637)

.329

1.141 (0.093

– 13.984)

.918

Primary task: direct patient care

Yes No*

6.266 (1.030 – 38.125)

.046

0.198 (0.034 – 1.147)

.071

1.055 (0.005 – 21.876)

.984

Primary task: education

Yes No*

8.021 (0.778 – 82.730)

.034

0.129 (0.014 – 1.117)

.069

3.734 (1.261 – 11.062)

.017

Presence of a reporting system

regarding experiences of aggression

Yes No*

40.326 (0.596 – 2729.453)

.086

32.319

(0.032 – 331.912)

.326

NA

NA

Commonly used system to report

aggression: verbal report with supervisor/line manager

Yes No*

2.493 (0.567 – 10.955)

.226

0.143 (0.021 – 0.958)

.045

0.771 (0.026 – 23.198)

.881

Commonly used system to report

aggression: report in specific place (e.g. a protocol)

Yes

No*

0.616 (0.121 –

3.139)

.559

1.283 (0.205

– 8.017)

.790

NR

NR

Commonly used system to report aggression: written report in

patient’s file Yes

No*

0.483 (0.097 –

2.412)

0.375

0.388 (0.090

– 1.666)

.203

NR

NR

*Reference category, °Odds ratio (95% confidence interval), Statistical significant P-values at the 0.05 level are in bold, A p<0.10 in univariate analyses are in Italic, NR = Not relevant, NA= Not applicable due to a lack of variance: independent variables

presumed to be associated variables based on a (1) univariate significant, (2) empirically or (3) theoretically or logically expected relationship with the dependent variable, which were lacking variance: ‘having to call in sick due to an aggressive incident’;

‘emotional impact of experiencing verbal aggression’, ‘emotional impact of experiencing threats’, ‘emotional impact of experiencing physical aggression’, ‘perceiving aggression as a functional or comprehensible phenomenon’


79

4. | Discussion

Our findings provide a comparison of nurses’ experiences of patient aggression and aggression of

patients’ family members across two different nurses’ work settings: the general hospital setting and the

primary care setting or community care setting. Significant differences were observed regarding the

prevalence of aggression, consequences of experiencing aggression, used support mechanisms

following experiences of aggression, training in the management of aggression, reporting of aggressive

incidents and perceptions regarding aggression and its management.

In line with other research, this study confirms and stresses how aggression is an important concern for

nurses irrespective of their work setting (Spector et al., 2014). Our findings on the prevalence of

aggression are similar to those reported in other studies (Hahn et al., 2013; Hanson et al., 2015) in the

same way as verbal aggression appears to be the most prevalent form experienced (Edward, Ousey,

Warelow, & Lui, 2014). Except for hospital nurses’ experiences of physical aggression by patients, all

forms of aggression were perpetuated more by patients’ family members than by patients. This

difference was more pronounced in primary care nurses than in hospital nurses. Primary care nurses

encountered significantly more verbal aggression of patients’ family members in comparison to hospital

nurses. This difference might be explained by work contexts as primary care nurses interact more with

family members in the private home setting (Geiger-Brown et al., 2007; Nakaishi et al., 2013). Moreover,

primary care nurses described a significant higher emotional impact of experiencing verbal aggression,

physical aggression and threats than hospital nurses. The private and sometimes isolated home setting,

or the lack of direct contact with colleagues (Da Silva et al., 2015) might explain this difference. Although

there were no differences in the types of support mechanisms used by both samples of nurses following

an aggressive incident, we did not assess the perceived meaning or impact of support of colleagues,

supervisors, etc. Even though primary care nurses gained support from colleagues following an

aggressive incident, the lack of direct contact with colleagues when aggressive incidents occur might

explain the higher emotional impact of aggressive incidents. As Barling et al. (2001) established, primary

care nurses have to rely on their own resources to manage aggressive incidents. The prominent

emotional impact of aggression is important to acknowledge since research indicates that a long lasting

overwhelming of one’s coping resources might result in prolonged stress (Denton et al., 2002) which

might lead to poorer mental and physical health outcomes of professionals (Hanson et al., 2015).

Hanson et al. (2015) adopt the transactional stress and coping theory (Lazarus & Folkman, 1982) and

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80

the social-learning theory (Bandura, 1982) to presume that nurses’ confidence in preventing and

responding to aggression mitigates the negative impact of aggression on one’s health. Our study

provides mixed evidence as primary care nurses described a significant higher emotional impact of

aggression in comparison to hospital nurses, while they also indicated to be significantly more confident

in using verbal and physical interventions to manage aggression. However, overall confidence levels of

both samples of nurses in managing aggression appear rather low to moderate. This finding warrants

further research to understand relationships between nurses’ confidence in managing aggression and

the emotional impact of experiencing aggressive incidents when they occur. This understanding would

generate insight to fine-tune interventions to support nurses in managing aggression.

In addition, associations between patient-related, nurse-related and work-related characteristics, and

nurses’ perceptions about aggression were examined. Having more working experience was associated

with perceiving aggression as a dysfunctional phenomenon, a finding confirmed in literature

(Abderhalden et al., 2002; Verhaeghe et al., 2016). When nurses’ primary task was the education of

nursing students, a higher likelihood of perceiving aggression as dysfunctional was observed. This

association might be explained by the higher workload of these nurses (McIntosh, Gidman, & Smith,

2014), or the protective role these nurses might adopt towards students, making them more prone to

perceive aggression as undesirable and disturbing. However, these are merely assumptions as there is

no literature to support these presumptions. Future work should explore relationships between nurses’

characteristics as working experience or organisational factors as workload and their influence on

perceiving patient’s behaviour as aggressive.

Predominantly working in direct patient care was associated with perceiving aggression as

dysfunctional. This association seems logical. More direct patient contact might result in nurses being

more exposed to patient aggression, leading to the perception that aggression is dysfunctional (Jansen

et al., 2005). Despite this presumption, other associations regarding the perception that aggression is a

functional phenomenon provide an additional understanding. Primary care nurses and nurses who

predominantly have contact with patient’s husbands or partners were more inclined to perceive

aggression as a functional phenomenon. Working in the patient’s home environment and interacting

with people close to the patient, might result in an understanding of patient’s behaviour even if it is

aggressive (Winstanley, 2005). This personal and long-term nature of caregiving is considered to be a

typical feature of community nursing (van Iersel et al., 2016).


81

Findings revealed how male nurses were more inclined to agree that aggression is comprehensible than

female nurses. Research on strategies male nurses use to manage emotions in nursing points out how

male nurses control own emotions as instrumental to the management of patients’ emotions. For

instance, remaining calm avoids adding to the emotions already present among patients (Cottingham,

2015). The de-escalating effect of managing own emotions to pre-empt patient’s belligerence might

influence perceptions of what patients’ aggression means. This can explain male nurse’s perception that

patient aggression is comprehensible.

It appears to be striking that predominantly working with patients over 65 years of age, and working with

patients’ parents are two factors associated with both perceiving aggression as a dysfunctional and as

a functional phenomenon. This finding seems quiet ambiguous, as it could be expected that nurses in

favour of the items constituting the perception that aggression is a dysfunctional phenomenon would

disagree with the items constituting the perception that aggression is a functional phenomenon. In line

with Abderhalden et al. (2002), nurses could have agreed to the two dimensions simultaneously. This

could demonstrate that the way aggression is perceived is more complex, encompassing agreement

with the notion that aggression can be both a functional and a dysfunctional phenomenon

(Vandecasteele et al., 2015). The perception of aggression might depend on specific clinical situations

(Jansen et al., 2005). For instance, when nurses have contact with predominantly patients’ parents,

parents might provide a contextual understanding of patients’ aggressive behaviour, which might lead

to the perception that aggressive behaviour can be functional. In contrast, research also identified

parents of paediatric patients to be a significant source of aggression (Pich, Hazelton, & Kable, 2013),

which might lead to circumstances in which aggression is perceived as dysfunctional. The same ‘double’

stand can be present in caring for older patients. Literature suggests aggression is highly prevalent in

geriatric settings, which might lead to the perception that aggression in is dysfunctional as a result of

the high exposure to aggression (Jansen et al., 2005). However, when caring for older patients some

contextual factors (e.g. the cognitive status of patients expressing aggressive behaviour) might be taken

into account leading to the perception that aggressive behaviour can be comprehensible and

understandable (Winstanley & Whittington, 2004; Vandecasteele et al., 2015). This ambiguity might be

a limitation of using the POAS-s. In this instrument, aggression is assessed on very general levels

whereas the specificity of particular aggressive incidents might have a more profound influence on how

Chapter III

82

aggression is perceived (Abderhalden et al., 2002). Future research is required to determine what

underlying processes are at play in perceiving patient’s behaviour as aggressive.

As an implication for practice, the findings on the reporting of aggressive incidents ought to be

considered. The majority of nurses indicated they did not, or only limitedly, formally report aggressive

incidents. The finding that a lot of nurses did not know whether formal reporting systems were present

has to be taken into account. The finding of underreporting aggressive incidents is internationally

acknowledged (Sato et al., 2013). Present findings contribute to this literature as an association was

found between commonly used structures to formally report aggression and the perception that

aggression is a comprehensible or functional phenomenon. When it was common to report with the

supervisor, the likelihood that aggression was perceived as functional decreased. This finding can be

contrasted with the finding that nurses, when they gained support from supervisors following aggression,

the chance that aggression was perceived as dysfunctional decreased. This finding emphasises that

mere reporting of incidents to supervisors is insufficient, a supportive context and a tenet to search for

what makes aggression understandable seems to be important to decrease the risk that the experience

and seriousness of aggression will be amplified. As an implication for research, it would be interesting

to understand nurses’ perceptions regarding different types of aggression. When nurses experienced

threats in the past 12 months, they were more inclined to perceive aggression as a dysfunctional and

undesirable phenomenon. This finding seems straightforward as direct experiences of aggression can

have a profound influence on perceptions of aggression (Jansen et al., 2005). However, experiencing

verbal or physical aggression did not seem to influence nurses’ perceptions of aggression. This finding

warrants exploration through research. Qualitative inquiry into the meaning of different types of

aggression would enable greater understanding of the (lack of) associations found here.

4.1. | Methodological considerations

A limitation is the cross-sectional nature of the study which does not allow to determine causality. This

is important in interpreting results of regression analyses. Another limitation pertains to the low response

rate in one of the departments in primary care (27.8%) where nurses were conveniently sampled. This

can introduce bias (Polit & Beck, 2017). Comparing both departments in primary care rendered no

significant differences in nurses’ experiences of patient aggression or aggression of patients’ family

members. In addition, recall bias can be present as the instruments adopt a 12 month time frame to

assess experiences of aggression. This induces the risk that one extreme aggressive incident


83

profoundly influences recollections of aggression. As the 12 months’ time frame is a commonly used

time frame to assess aggression in healthcare (Hahn et al., 2013), this time frame was adopted to allow

international comparison of findings.

5. | Conclusion

Aggression in healthcare is not a new problem. The findings from this study present a unique insight

into experiences of aggression of nurses working in primary care and general hospital settings, and into

the factors associated with nurses’ perceptions regarding aggression and its management. Irrespective

of work setting, the study confirms how aggression in nursing is highly prevalent, suggesting a negative

impact on nurses’ work, professional practice and overall well-being. Different factors (nurses’ gender

job experience, level of employment, work setting, primary tasks and exposure to aggression; contact

with patients’ family members and patients’ ages) were found to be associated with nurses’ perceptions

of aggression. There is a need for closer investigation of associations between nurses’ working

experience, nurses’ workload and the perception that aggression is a dysfunctional phenomenon. As

we cannot assume the cross-sectional associations we observed are causal, further work is warranted

to understand how certain perceptions of aggression emerge, how they influence nurse’s behaviour,

and what underlying processes are present in perceiving patient’s behaviour as aggressive.

Chapter III

84

Table 4. Supplementary material. Univariate associations between individual independent variables

and dependent variables (univariate analyses – p<0.10).

Variables

Elements

Perceptions of aggression

Perceptions of the management of

aggression

Perceiving aggression

as a

dysfunctional phenomenon

Perceiving aggression

as a

functional phenomenon

Perceiving intervention

strategies as

important

Perceiving preventive

strategies as

important

Nurses’ characteristics

Gender NS 0.059 NS NA

Work setting NS 0.048 0.024 NA

Educational degree NS NS 0.078 NA

Level of employment NS NS NS NA

Job experience in current position 0.020 NS NS NA

Training level in aggression management

NS NS NS NA

Perceived importance of training in aggression management

NS NS <0.001 NA

Perceived confidence in managing verbal intervention skills

0.063 NS NS NA

Perceived confidence in managing physical intervention skills

NS NS NS NA

Nurses’ experiences of aggression

Having encountered aggression in the professional career as a nurse

NS NS NS NA

Having encountered verbal aggression in the past 12 months

NS NS NS NA

Having encountered verbal aggression perpetuated by patients in the past 12 months

NS NS NS NA

Having encountered verbal aggression perpetuated by patients’ family members in the past 12 months

NS NS NS NA

Having encountered threats in the past 12 months

NS NS NS NA

Having encountered threats perpetuated by patients in the past 12 months

NS NS NS NA

Having encountered threats perpetuated by patients’ family members in the past 12 months

NS NS NS NA

Having encountered physical aggression in the past 12 months

NS NS NS NA

Having encountered physical aggression perpetuated by patients in the past 12 months

NS NS NS NA

Having encountered physical aggression perpetuated by patients’ family members in the past 12 months

NS NS NS NA

Having to call in sick due to an aggressive incident

NA NA NA NA

Emotional impact of experiencing verbal aggression

0.071 NA NS NA

Emotional impact of experiencing threats

NS NA NS NA

Emotional impact of experiencing physical aggression

NS NA NS NA

Frequency of formally reporting aggressive incidents

0.035 NS NR NA

Support following aggressive incident: discussion with supervisor

NS NS NS NA


85

Support following aggressive incident: discussion with partner

NS NS NS NA

Support following aggressive incident: discussion with friend/family

NS NS NS NA

Support following aggressive incident: discussion with colleague

NS NS NS NA

Perceiving aggression as a dysfunctional phenomenon

NA NA NS NA

Perceiving aggression as a functional phenomenon

NA NA NA NA

Perceiving intervention strategies as important

NS NA NA NA

Perceiving preventive strategies as important

NA NA NA NA

Patients’ characteristics and family members’ characteristics

Patients’ age: up to 12 years NS NS 0.031 NA

Patients’ age: 12-18 years NS NS NS NA

Patients’ age: up to 65 years NS NS NS NA

Patients’ age: over 65 years 0.100 NS 0.003 NA

Contact with family members: mostly husband/wife/partner

NS NS 0.010 NA

Contact with family members: mostly siblings

NS NS NS NA

Contact with family members: mostly parents

NS NS NS NA

Contact with family members: mostly children

NS NS 0.047 NA

Practice characteristics

Percentage direct patient contact time

NS NS NS NA

Primary task: direct patient care NS 0.055 NS NA

Primary task: supervisor/management

NS NS NS NA

Primary task: expert function NS NS NS NA

Primary task: education (internships)

NS 0.066 0.042 NA

Organizational characteristics

Presence of a reporting system regarding experiences of aggression

NS NS 0.033 NA

Commonly used system to report aggression: verbal report with supervisor/line manager

NS 0.002 NS NA

Commonly used system to report aggression: report in specific place (e.g. a protocol)

NS NS NS NA

Commonly used system to report aggression: written report in patient’s file

NS 0.011 NS NA

NS= not significant, NA= not applicable due to lack of variance in the dependent variable, NR=not relevant

Chapter III

86

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71(12), 2786-98.

Vandecasteele T., Van Hecke A., Debyser B., Vanderplancke T., Beeckman D. & Verhaeghe S. (2017) Assessment

of patients’ and family members’ aggression directed towards nurses working in general hospital settings: validation

of three instruments. Submitted manuscript.

Verhaeghe, S., Duprez, V., Beeckman, D., Leys, J., Van Meijel, B., & Van Hecke, A. (2016). Mental Health Nurses'

Attitudes and Perceived Self-Efficacy Toward Inpatient Aggression: A Cross-Sectional Study of Associations With

Nurse-Related Characteristics. Perspectives in psychiatric care, 52(1), 12-24.

Waschgler, K., Ruiz-Hernández, J.A., Llor-Esteban, B., & García-Izquierdo, M. (2013). Patients’ aggressive


users. Journal of Advanced Nursing, 69, 1418–27.

Wei, C.Y., Chiou, S.T., Chien, L.Y., & Huang, N. (2016). Workplace violence against nurses – Prevalence and



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Journal of Advanced Nursing, 39, 230-40.

Whittington, R. (2002). Attitudes toward patient aggression amongst mental health nurses in the 'zero tolerance'

era: associations with burnout and length of experience. Journal of Clinical Nursing, 11(6), 819-25.

Williamson, E., Jones, S.K., Ferrari, G., Debbonaire, T., Feder, G., & Hester, M. (2015). Health professionals

responding to men for safety (HERMES): feasibility of a general practice training intervention to improve the

response to male patients who have experienced or perpetrated domestic violence and abuse. Primary health care

research & development, 16(3), 281-8.


perceptions of the context and assailants' levels of cognitive processing. Aggressive behaviour, 30(6), 534-543.

Winstanley, S. (2005). Cognitive model of patient aggression towards health care staff: The patient's perspective.


Patients’ perceptions of transgressive behaviour

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Chapter IV.

PATIENTS’ PERCEPTIONS OF TRANSGRESSIVE

BEHAVIOUR IN CARE RELATIONSHIPS WITH NURSES

Tina Vandecasteele1,2, Bart Debyser2, Ann Van Hecke1,3, Tineke De Backer2, Dimitri Beeckman1,

Sofie Verhaeghe1,2





Based on the article of Vandecasteele T., Debyser B., Van Hecke A., De Backer T., Beeckman D. &

Verhaeghe S. (2015) Patients’ perceptions of transgressive behaviour in care relationships with nurses:

a qualitative study. Journal of Advanced Nursing. 71(12), 2822–2833.

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93

Patients’ perceptions of transgressive behaviour in care relationships with nurses: a

qualitative study

ABSTRACT

Aim. To gain insight in the onset and meaning of transgressive behaviour in care relationships with

nurses, from the perspective of patients.

Background. Aggression and transgressive behaviour in healthcare have been a focus of research

over the last decades. Most studies describe staff experiences on patient aggression. Patient’

perspectives on aggression and transgressive behaviour in interactions with nurses are rarely sought.

There is a need to better understand the meaning of transgressive behaviour from the patient’

perspective.

Design. Qualitative interview study.

Methods. Twenty patients were purposefully sampled from six wards of two general hospitals. Semi-

structured interviews were carried out in 2011. Data were analysed using the constant comparative

method inspired by the grounded theory approach.

Findings. On elaborating on what constitutes experiences of transgressive behaviour, patients employ

a framework of suppositions towards hospital care and nurse–patient relationships. This framework

leads to implicit ideas on how competent professional caregivers will be and on how relationships with

nurses will be characterized as normal human interactions. When these anticipated ideas are not met,

patients feel obliged to address this discrepancy by adjusting their expectations or behaviour. Patients

become more vigilant with regard to care given by nurses; search for own solutions; make excuses for

nurses or reprioritize their expectations. Because of this adjustment, perceptions of transgressive

behaviour are reinforced, mitigated or put into perspective.

Conclusion. This study offers an understanding of what underlying process patients go through when

interacting with nurses and how perceptions of transgressive behaviour can take place or evolve in these

interactions. Patients appear to adjust their own expectations or behaviour based on what they

experience in care relationships with nurses or the professional care in the hospital. It is crucial that

patients feel free to discuss their expectations or untoward needs, and nurses learn to understand and

reflect on those experiences.

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Keywords. Aggression, general hospital, nurse–patient relationship, nurses, nursing, patient, patients’

experiences, qualitative research, transgressive behaviour, violence.


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1. | Introduction

The article addresses the meaning of transgressive behaviour from the patient’s perspective in a general

hospital ward setting. Data are reported where patients describe in their own words their perceptions of

transgressive behaviour in care relationships with nurses. Data were obtained as part of a larger

qualitative study exploring the onset and meaning of transgressive behaviour in the dynamics of nurse–

patient care relationships.

1.1. | Background

Aggression in healthcare have been a focus of research over the last decades (Spector, Zhou, & Che,

2014). Extensive research has been conducted to understand the phenomenon of aggression in care

relationships between caregivers and patients (Hahn et al., 2008; Hahn et al., 2012). Most of the

research relates to geriatric (Almvik, Rasmussen, & Woods, 2006; Duxbury, Pulsford, Hadi, & Sykes,

2013), emergency (Gerdtz et al., 2013) and mental health settings (Abderhalden et al., 2007). Relatively

few attempts have been made to examine aggression in general healthcare settings (Winstanley &

Whittington, 2004; Hahn et al., 2008).

This study has two distinct presuppositions. The first is the focus in literature on staff experiences with

different types of patient aggression. Most of the studies investigate precursors or antecedents of

aggressive behaviour. These are performed by measuring risk factors associated with patient

aggression (Hahn et al., 2010; Hahn et al., 2013) or by retrospective surveys where healthcare providers

indicate to what extent they are exposed to specific physical, verbal and non-verbal aggressive

behaviours (Foster, Bowers, & Nijman, 2007; Abderhalden et al., 2008; Yang et al., 2012). Several

patient characteristics, workplace characteristics and characteristics of patient and healthcare provider

interactions have thus been identified to contribute to patient aggression (Hahn et al., 2008). The

majority of studies describe staff experiences in relation to patient aggression or difficult patient’

behaviour (Koekkoek, Hutschemaekers, van Meijel, & Schene, 2011). The patient’s perspective on

aggressive or difficult nurses’ behaviour is rarely sought. However, on a more general level, patients’

views of healthcare are considered an essential component of health service evaluations. They are used

to assess how well services are provided at a local level (McPherson, Kayes, Moloczij, & Commins,

2014); to obtain feedback to healthcare workers to improve quality of care (Cominskey, Coyne, Lalor &

Begley, 2014), or as an outcome measure to evaluate organizational changes (Metzelthin et al., 2013).

In literature, patient satisfaction surveys are regarded as a valid method to obtain patients’ views of

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healthcare and are as such frequently used (You et al., 2013; Lehto, Helander, Taari, & Aromaa, 2014).

Nevertheless, reservations exist about the validity of patient satisfaction as a concept and instruments

to measure it (Williams, 1994; Bruyneet et al., 2017). In recent years, the focus has shifted from patient

satisfaction to exploring dissatisfaction with healthcare (Söderberg, Olsson, & Skär, 2012; Howard,

Fleming, & Parker, 2013). The concept of dissatisfaction is believed to redirect attention to problems

experienced by patients and has mainly been explored by analysing formal complaints (Veneau &

Chariot, 2013; Zengin et al., 2014). However, these studies exclude negative experiences that are not

translated into formal complaint and as such do not seem sensitive enough in eliciting disappointment

or negative experiences with healthcare (Coyle & Williams, 2001).

The second presupposition of this study is related to the operationalization of aggressive or difficult

nurses’ behaviour. The broader term ‘transgressive behaviour’ was used. In literature, different

definitions of the concept of aggression exist, highlighting different elements (Liu, 2004; Nijman, Bowers,

Oud, & Jansen, 2005; Liu, Lewis, & Evans, 2013). These elements were merged into the following broad

definition of aggression: ‘Inflicting harm to material or to another person by transgressing the other

person’s limits, standards, or norms’. This study drew on the latter part of this definition: ‘transgressing

of limits, standards, or norms’. This notion assumes that experiences of transgressive behaviour can

vary from person to person as perceptions of an aggressive act is an internal personal construct

(O’Connell et al., 2000). Use of this term allows an individual interpretation of when and what limits are

exceeded for situations to be experienced as transgressive and which factors influence this process. In

literature, ‘transgression’ is commonly combined with moral or ethical values or principles as boundaries.

This particular conceptualization presumes certain moral or ethical suppositions which have to be

crossed for a moral or ethical transgression to occur. In this study, particular ethical or moral principles

were not defined or expected to be at stake when perceiving transgressive behaviour. Furthermore,

transgressive behaviour is situated in patient–nurse relationships and patient–nurse interactions. The

interpretation of limits, how they are exceeded, the perceived seriousness of the situation and the

processes involved in this interpretation, were not determined in advance. The overall aim of the study

is to provide a better understanding of perceptions of transgressive behaviour in care relationships from

the perspective of patients.


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2. | The study

2.1. | Aim

The aim of the study was to provide a better understanding in which cases nurse behaviour is perceived

as transgressive and what it is like for patients to experience transgressive behaviour in patient–nurse

relationships. The long-term goal is to combine the patient perspective with the nurse perspective

(reported in another publication) in an integrative analysis to provide an overall perspective of

transgressive behaviour in the dynamics of patient–nurse care relationships.

2.2. | Design

A qualitative study according to the grounded theory was conducted as this study focused on clarifying

and understanding patient perceptions of transgressive behaviour (Glaser & Strauss, 1967; Morse &

Field, 1996; Hallberg, 2006).

2.3. | Participants

Participants were recruited in 2011 in six wards located in two general hospitals in Belgium. These

hospitals serve both rural and urban communities situated in West Flanders, a Dutch-speaking Belgian

province. To recruit patients, student nurses were informed about the study and asked to distribute

closed envelopes with an information letter to patients of different wards. Included wards had a

diagnostic, medical, geriatric or surgical focus. Patients had to be admitted for a minimum of three days

which meant each patient had communicated regularly with nurses during their stay. When patients

gave their consent, a researcher visited the patient to answer questions and to get acquainted. Twenty

patients participated. Patients’ characteristics are presented in Table 1. The sample comprised a range

of participants in terms of age, educational level and reasons for hospital admission.


Data were collected using semi-structured interviews with open-ended questions. The interviewers

adopted a conversational and emphatic approach, guided by a topic list and patients’ answers. Patients

were encouraged to tell their story. Each interview started by asking the patient to describe an incident

he or she perceived as transgressive. From that point on, interview techniques elicited more details

about these perceptions. Table 2 provides examples of frequently asked questions. The topic list was

initially guided by sensitizing concepts derived from literature and was gradually adjusted to new insights

gained from analysis of interviews. To broaden initial insights and to select participants for subsequent

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interviews, theoretical sampling was used (Draucker, Martsolf, Ratchneewan, & Rusk, 2007). After 14

interviews, interviews were held with four patients who were labelled ‘difficult patients’ by several nurses.

These patients were sought to understand how they perceive care relationships and how they thought

they were perceived by nurses. Interviews were held shortly before hospital discharge or during the first

weeks afterwards and took place in the hospital or in the patients’ home. Each interview lasted between

20–81 minutes (average duration: 40 minutes). During and immediately after each interview, the

interviewer made field notes about patient’s non-verbal expressions and wrote down initial ideas about

the story of the patient or own perceptions of the interview. All interviews were tape-recorded. Audio

recordings were transcribed verbatim by a professional transcription service. Identifying data mentioned

in the interviews were deleted. Two analysts checked each transcript against the recording for accuracy.

Hence, they immersed themselves in the data and became sensitive to issues of importance. These

analysts uncovered and added information on reflection about participants’ expressions and reactions.


Approval by the Ethical commission of the VIVES University College was provided. Written informed

consent was obtained. As patients were asked about nurses’ behaviour, confidentiality and anonymity

were stressed. The researchers were not known to any of the participants.


Interviews were read and re-read entirely to obtain an overall picture of the interview and to get

familiarized with the data. Meaningful content of the interviews was comprehensively described and

subsequently coded using the NVIVO software package (QSR International). Fragments with the same

code were compared using the constant comparative method. By using initial inductive coding, by

comparing interviews and coded fragments and by considering possible meanings of the data, initial

ideas about conceptual constructs emerged. The process of data analysis occurred simultaneously with

data collection. This approach allowed to guide data collection based on emerging theoretical insights

and allowed to reach data saturation (Charmaz, 2008).


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Table 1. Characteristics of participants.

Patients (N=20) Patients (N=20)

Gender (female) 11 Living circumstances Age category (years) Living alone 9

30-40 1 Living with partner/other 11 40-50 5 Previous hospital admissions

50-60 6 Yes 18 60-70 7 No 2 80-90 1 Hospital wards

Educational level (years of education) Neurology & Neurosurgery 1 High (>18) 7 Neurological & Locomotor

rehabilitation

4 Medium (16-18) 7 Orthopaedic surgery &

Traumatology

8 Low (<15) 5 Cardiology & Pulmonology 2 Unknown 1 Oncology 1

Nephrology 4

2.7. | Rigour

Several strategies were used to increase trustworthiness of the data and the analysis. Investigator

triangulation expanded the depth of our understanding of data, thus contributing to the overall goal of

triangulation of increasing the likelihood findings and interpretations will be found credible and

dependable (Lincoln & Guba, 1985). At regular intervals, four researchers compared and discussed data

and checked analysis along with acquired data. All researchers had experience in qualitative research

while one researcher had extensive experience in grounded theory research. Employing reflexivity and

peer debriefing prompted to change interview styles, clarify analysis and explicate understandings of

data. Reflection was used purposefully throughout the analysis. A meticulous audit trail was used to

capture decisions regarding sampling and to describe structure and rationale of meanings assigned to

data, which strengthened dependability (Lincoln & Guba, 1985). With regard to patients’ perspectives,

the same assumptions about hospital care and care relationships with nurses and the same underlying

processes were encountered, suggesting redundancy was reached (Trotter, 2012).

Table 2. Examples of frequently asked questions.

How do you understand transgressive behaviour? Can you provide an example?

How did you feel about that incident? What was it like for you?

Can you describe what happened? What did the nurse do? What did he/she say? How did you feel

about that reaction? How did you respond? Did you do something about it, or not?

How did you cope with that experience? What made it difficult? What stimulated you? How do you

look back on that? What was the following contact with that nurse like for you?

Did you talk about it with someone? What did you tell them? What was it like to talk about it?

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3. | Results

During the interviews, all patients originally declared to be satisfied with the care they were given in the

hospital, and with the nurse – patient relationships. Patients stated that nurses were friendly, that they

did not have important remarks and that, overall, they did not have complaints:

“… Generally speaking, it’s all right. I don’t have complaints, really. No, overall, I don’t have any

complaints about the hospital, no complaints, so generally…”

Patients uttered that the experienced care generally meets their expectations. The most important

problem patients can initially think of is that hospital food is not nice. However, as patients gave a more

detailed account of their specific experiences, their satisfaction became less pronounced. Very

cautiously, perceived satisfaction was toned down.

“… There was the occasional nurse who was not as friendly…”

“…The thing I could come up with is that the people who are working there have too much to

do, to the point where they don’t have enough time to take care of you properly…”

Gradually, patients spontaneously started to tell stories about experiences with nurses that were not as

positive and interactions they felt were transgressive. The nature of these examples varied greatly.

Some stories concerned medical or health-related matters, while others concerned communication and

interactions. Some patients told about how a nurse did not know how to fit a prosthesis and hurt the

patient in the attempt; another nurse did not recognize a patient was having an epileptic seizure; nurses

took up to 30 minutes to answer calls; a nurse refused to administer pain relief; a nurse made the remark

that the patient was addicted to a type of medication; dinner was taken away by the nurse while the

patient was not given the time to finish it, etcetera.

As patients were describing these various incidents, they went into further detail about what exactly

made it a bad or transgressive experience. An explanatory process of how experiences of transgressive

behaviour emerge is described below.

3.1. | Framework of suppositions: ‘Competent care and human interaction, surely that

is self-evident?’

When patients are admitted to the hospital, they envisage what care and nurse – patient relationships

are going to be like. They have general ideas or suppositions about what it is like to be hospitalized.


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[Author’s note: The term supposition is understood as: ‘An idea or notion sufficiently probable to be

practically assumed as true, or to be at least admitted as possibly true, on account of consistency with

known facts’ (English Oxford Dictionary)] These general ideas concern two domains. The first domain

pertains ideas about hospital care. Patients feel they will be in competent and capable hands in a

hospital. Because of patients’ specific circumstances of illness or rehabilitation, they need hospital care.

From this perspective, they expect care providers who are able to give adequate and competent

responses to their illness and care related needs:

“…I assume they know how to do their job. They know all this stuff, I don’t, so I need to listen to

them. It’s their job, they went to school for these things, I assume it’s their area of expertise, I

assume they know about this…”

The second domain of patients’ visualization concerns ideas about the nurse – patient relationship.

Patients think about how they will have normal human contact or normal human interactions with nurses.

They have the idea they will be heard and seen as human beings, despite the fact they are in a hospital

as patients:

“…that they act completely normal, it should all be very normal, (. . .) human, acting normal,

have some respect, a little compassion...”

“…You assume they know their job, but you also expect a little more than that...”

These two suppositions are considered to be self-evident and logical. These are thought to be normal

ideas about what hospital care and nurse – patient relationships are going to be like. These assumptions

add a factor of predictability to a patient’s stay in the hospital. The assumptions are not considered

special or exceptional, they are part of a natural framework of suppositions.

3.2. | Experiencing discrepancies: ‘Competent care and human interaction, is it not

self-evident after all?’

Those two suppositions are tacit and rather implicit. Patients are not always aware they have these

suppositions. This realization hits them when their assumptions are not met. When patients do not feel

they are getting competent care or human interactions, they become aware they initially formed ideas

about care and care relationships. It is only then patients become aware of these previously made

suppositions. Non-fulfilment of suppositions causes them to experience indignation. There is a

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discrepancy between self-evident assumptions and the perceived reality. Subsequently, competent care

and human interactions are no longer perceived as self-evident.

When it comes to competent care, some patients told stories in which the expertise of the care providers

was questioned. One patient described a nurse provided pain relieving medication while he is allergic

to that product. In response, the patient’s daughter attached a list to her father’s bed listing products he

is allergic to. Despite this list, every time her father asked for pain relief, that same product he is allergic

to was brought to him. Another patient described a nurse accompanied him for an examination. He

asked where she was taking him to and when she said it was to Nuclear Magnetic Resonance, he said

he was not allowed to because of his pacemaker. He indicated the nurse had not gone through his

medical file and was putting him in danger.

“…I can see something’s going on with that man, she just leaves and ignored him and all of a

sudden I can see him shaking, an actual epileptic seizure. . . they don’t even recognize it. What

have they gone to school for? I think that’s really sad…”

The second supposition made by patients concerns the nurse – patient relationship and the human

interactions patients envision as part of that relationship. Patients told stories of how they were ignored

by nurses or not treated as human beings. One woman described the nurse criticized her for not having

to have worked a day in her life because of her long-term illness. Another man described dinner was

put in front of him without a single word, no ‘good afternoon’ or ‘enjoy’. Patients also provided examples

of a lack of genuine involvement of nurses in the nurse – patient contact. Various patients mentioned

they felt they were just a “number”:

“…One thing that is very annoying is when two nurses are caring for you and they are conversing

with each other over your head. That’s so annoying, you really feel like just a number…”

Furthermore, various patients indicated nurses are more concerned about the way care is organized

than they are about the patient’s request. Patients mentioned that nurses stick to their routine and are

reluctant to deviate from it. One nurse distributes medication while another checks parameters of all

patients. Patients describe they cannot approach the nurse about matters that are not part of his or her

task at that moment:

“…But when it comes to organization as such, they all have their own task.. Don’t bother asking

a nurse to do this or that, because someone who’s serving dinner is then going to collect the


103

trays. It’s often something small. ‘Could you switch on my nebulizer?’. They’re doing their

rounds, it’s a strict routine. They refuse to deviate from it…”

Various patients gave examples of situations in which they were not acknowledged or heard with regard

to their own appraisal or expertise concerning their illness and health. Patients stated that they

themselves felt what they could or could not do, but nurses kept emphasizing and imposing things,

according to guidelines and protocols, they should be able to do at a certain point in time. Several

patients felt they were not heard.

“…I had two surgeries on my back. So the first day after the surgery, they said, ‘roll to the side

and sit up’, of course that’s difficult. On the second day, they demand you get out of bed. But I

felt worse, I couldn’t get out. And they didn’t believe me, the nurse didn’t believe it. ‘You’ve had

surgery and according to the text-book, you should be able to get out of bed on the second day’.

On the third day, they made a new scan and saw that those nerves had not been unblocked

and on the fourth day I had another surgery. So they don’t listen, because that’s not possible,

according to the ‘textbook’ you should be able to do this…”

Because of these experiences, patients develop a different view of hospital care and nurse – patient

relationships. Receiving competent care and having human interactions with nurses are no longer

considered self-evident or logical. The trust patients used to have in hospital care and nurse – patient

relationships is still present, but carefully toned down.

3.3. | And now what?: ‘Apparently, competent care and human interactions are not

self-evident’

When patients gradually realize that hospital care and nurse – patient relationships are not what they

thought it would be, they become distressed. Receiving competent care and having human interactions

are no longer self-evident, which forces patients to adapt to these new perceptions. These experiences

have different effects. Several patterns are put into action: patients become more vigilant with regard to

care given by nurses; they search for their own solutions; they make excuses for the nurses or they

reprioritize their expectations.

Dealing with perceived discrepancies: ‘You do pay more attention’. When patients realize it is not

self-evident to receive adequate care or do not feel in competent and capable hands, they become more

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observant and vigilant. Patients describe they observe nurses carefully, check their medication and ask

which examinations they are having and why. The care they receive is more outspokenly questioned.

“…They came to collect me for my hip. Ah, you’ve got a scanner appointment. She says: ‘it’s an

MR scan’. I say: ‘an MR scan? I can’t do that because I’ve got a pacemaker.’ And she says ‘And

now you tell me?’ ‘Listen here, missy, you walk in here and tell me to come.’ You’d be in there

if you wouldn’t have said something, wouldn’t you! The battery can generate voltage which could

burn your heart, destroying your pacemaker. If you’re not paying attention, you’re done for. You

constantly have to be on your guard…”

Numerous patients mention that they have become more vigilant when they are in hospitals because of

experiences during previous hospitalizations. Previous experiences taught people what competent care

is or what is to be expected from care providers. Patients acknowledge their attitude towards nurses

became sterner. They report to have learnt to be assertive and vocal when it comes to expressing their

dissatisfaction.

“…I know that, when you’re in hospital, you’re supposed to keep quiet. It’s not the first time I’ve

been in hospital. If you’re good and you’re afraid to say anything, it’s not going to help you. You

have to advance and then you’ll get what you need. If you don’t stand your ground and you

never say anything, they’ll think you’re an easy-going patient, but they’ll also ignore you…”

Dealing with perceived discrepancies: ‘I take care of it myself’. Some patients look for solutions on

their own when hospital care and nurse – patient relationships do not meet their expectations. They no

longer expect to receive certain aspects of caregiving in nurse – patient care relationships. They search

for other solutions. One woman described her neighbour helped her out of bed every time she needed

to use the bathroom. Otherwise, she had to wait too long for nurses to come. As this solution worked

perfectly well, she no longer called nurses.

“…You’re in pain, trying to find a comfortable position and you can’t and you ask for a simple

painkiller, just some paracetamol, not morphine or something and they won’t give it to you. Well,

I said, you know what, I won’t ask anymore and I didn’t. I asked the boys to bring some

paracetamol from home. I had some in the cupboard. That’s me, taking care of myself...”

Dealing with perceived discrepancies: ‘It is annoying, but not their fault’. Some patients adapt or

adjust their expectations. They realize their assumptions do not correspond with the reality of hospital


105

care so they adapt their expectations from nurses or keep them to a minimum. They start calling nurses

less and only do so when it is urgent, or try to understand when medication errors are made when

several patients with the same surname are on the same ward, or they know it can take long for nurses

to answer calls so they call in advance if they need to use the bathroom.

“…I didn’t ask a lot, I waited until they came around and if it was urgent, I called out when

someone was passing in the hallway and I asked for someone to come around...”

“…No, they never addressed me by my name. But I don’t expect them to. You can’t expect them

to know every patient’s name, can you. With all those patients coming and going, how can

they…”

Other patients minimize their needs by taking into account the needs of their fellow patients. They

consider the fact they are not alone and that the nurses’ time has to be divided among all patients. Since

nurses have a lot of patients to care for, patients adjust their expectations of care that can be provided

to them:

“…We weren’t difficult patients. I know that everyone in there is ill too. You can never think

you’re the only one there. I keep that in mind…”

Various patients take the nurses’ working context into consideration. The perceived discrepancy

between their suppositions of hospital care and the reality is thus minimized. This discrepancy is linked

to matters that do not fall within the nurses’ responsibilities. The way care is organized, or shortage of

staff is given as reasons for why patients feel they are not treated as human beings. Nurses themselves

are not viewed as the cause of discrepancies. Although care relationships may not meet patients’

expectations, it does not appear to be the nurses’ fault. They can-not help it either.

“…Well, the problem is they don’t have enough staff. There’d be less problems if there was more

staff, they’d be less cranky...”

“…If you have to use the bathroom or something like that, it can take quite a while for someone

to come and help you. But I know that there’s a shortage of staff everywhere, it’s not their fault…”

Dealing with perceived discrepancies: establishing priorities. Some patients discover both their

suppositions of competent hospital care and human interactions with nurses are not met. One patient

declares he called the nurse because his neighbour was unwell. The nurse did not answer the call until

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half an hour later and when he talked to her about the long waiting time, she told him to be more polite.

When he discussed this experience further, he said he found the long waiting time worse than the

nurse’s retort. The fact it took half an hour to answer calls, was more important and serious to him.

Another patient told a nurse her drip kept getting infected. She knew from a previous stay on another

ward that a special lock could avoid needing a new drip every time it got infected. She further narrates

the nurse waved her aside and said they did not have time for it. The patient described she feels more

strongly about not getting the special lock than she does about the nurse’s rude reply. When judging

what is worst, patients consider what has the biggest impact or is most relevant to them personally. Not

having human interactions is thought to be less important than not receiving competent care. The worst

is whatever is most threatening on a personal level. A quadriplegic woman illustrates this.

“…If they’re late or cranky or whatever. Well, small things like that, I won’t react, but if it concerns

me personally, I will do something, if I know it’s not right…”

Patients feel annoyed when they do not experience human interactions in nurse – patient relationships

but they consider it inconceivable when they feel nurses’ expertise is of a questionable level.

3.4. | Integration: What (exactly) is transgressive (behaviour)?

Patients can report to be ‘satisfied’ while there is a complex underlying process of being confronted and

dealing with negative experiences about hospital care and nurse – patient relationships. Patients have

an implicit framework of suppositions. Based on this framework, hospital care and nurse – patient

relationships are evaluated. The framework generates implicit assumptions or ideas about hospital care

and nurse – patient relationships. Patients envisage receiving competent care and having human

interactions with nurses. These suppositions are considered to be self-evident and logical. Patients do

not have second thoughts about these suppositions. Both the framework and suppositions appear to be

implicit. They are not discussed with nurses and patients are not aware of these assumptions until they

experience envisaged care or nurse – patient relationships are not met in the perceived reality.

Experiencing these discrepancies gives rise to a process of adaptation. Consciously or otherwise,

patients feel bound to act on those discrepancies. It is both a cognitive and emotional process where

discrepancies give rise to an adjustment of assumptions or behaviour. This adjustment results in patients

becoming more vigilant or assertive to bring up questionable expertise in contact with nurses. Other

patients are more likely to adjust their expectations and no longer think human interactions with nurses


107

are self-evident. These patients make excuses or look outside the nurses’ responsibility for causes of

negative experiences. Consequently, when pointing out the ‘worst’ part of a negative experience,

patients attach great importance to nurses’ expertise. They find it annoying to feel not treated in a human

way but it is minimized and put into perspective more quickly. Errors or questionable competencies of

nurses are considered to be inconceivable and are not as easily minimized or excused. A comparative

assessment is made to decide which factor affects patients most, personally or health-wise. Although

rude replies are annoying, they are less disturbing than professional errors with potentially major

consequences.

Due to the framework of suppositions and the process of adjustment in case experiences do not

correspond with assumptions, experiences of transgressive behaviour are put into perspective.

Whenever patients describe experiences of transgressive behaviour, the transgressive aspect of it is

mostly subjective. It is difficult to make objective determinations of what can and cannot be classified as

transgressive behaviour. Because of the process of adjustment, patients will tone down their opinion

about incidents that were experienced as transgressive. By making excuses, nurses are no longer the

cause of problems. By searching for solutions on their own, patients no longer need to address nurses

in case of problems. Experiences of transgressive behaviour are ‘addressed’ by the patient. This might

explain why patients’ ‘satisfaction’ was emphasized at the beginning of the interviews and incidents of

transgressive behaviour were voiced only gradually.

4. | Discussion

The study sought to better understand which nurse behaviour is experienced as transgressive by

patients and what constitutes this perception. The findings demonstrate that behaviour in itself does not

determine ‘what’ is experienced as transgressive. We described an underlying process patients go

through when interacting with nurses and how perceptions of transgressive behaviour can take place or

evolve in these interactions. Present findings demonstrate that patients employ a framework which leads

to implicit suppositions about professional care in the hospital and personal care relationships with

nurses. This framework generates ideas on how competent and skilled professional caregivers will be

and how relationships with nurses will be normal human interactions. Subsequently, a process of

adaption is employed when discrepancies are felt between these suppositions and the experienced care

or care relationship.

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4.1. | Interpretation and context of the results

The first major supposition to encounter competent and skilled professional caregivers might be

underpinned by a feeling of basic trust in nurses as professionals. A conceptual understanding of trust

and trustworthiness in nursing is provided by Dinç and Gastmans (2012). As a relational phenomenon,

impersonal trust in nurses is understood as having trust in nurses because institutions regulate practices

and endorse trustworthiness of professional activities (Dinç & Gastmans, 2012). Hence, expecting

competent professional care might be based on trust in nurses’ professional dispositions and

competencies as they are part of professional institutions. Likewise, competence adequacy of nurses

was identified as a normative expectation of patients in a grounded theory study on the meaning of

dissatisfaction of healthcare (Coyle, 1999a; Coyle, 1999b). Competence inadequacy, suggested as a

professionals’ lack of training, knowledge and expertise, accounted for an important untoward

experience of healthcare (Coyle, 1999a; Coyle, 1999b). Our findings demonstrate how perceiving

nurses’ competence inadequacy brought some patients to become alert or to adopt a sceptical attitude

towards nurses’ professional competences. Furthermore, experiences of competence inadequacy seem

to influence impressions of subsequent healthcare encounters. This notion is emphasized by our

findings as patients who had previous experience in healthcare, found their experiences empowering to

bring up untoward needs in contact with nurses.

The second major supposition is obtaining normal human interactions in care relationships with nurses.

When patients are admitted to a hospital, it is plausible they feel anxious and vulnerable. These feelings

are likely to increase because of unpleasant anxiety-provoking experiences commonly encountered in

hospitals (Winstanley, 2005). Hospitalization usually involves enforced confinement, a loss of privacy

and embarrassing situations, all of which might induce or exacerbate anxiety (Winstanley, 2005).

Inherent asymmetry in nurse – patient relationships might influence patients’ vulnerability and anxiety.

Power imbalances in nurse – patient relationships are found to contribute and increase patients’

vulnerability and dependency (Carter, 2009). Experiencing vulnerability and anxiety might impinge why

patients search for normal human interactions with nurses. Being seen as individuals or as human

beings might alleviate feelings of vulnerability of people who are or become recipients of healthcare

(Sellman, 2005).

Our findings demonstrate how patients deal with an untoward need for normal human interactions with

nurses. Although patients described nurses to have a primarily task-oriented approach, little attending


109

behaviour and little acknowledgement of patients’ appraisal about illness or health; they were not

inclined to blame nurses. They adjusted and lowered their expectations towards nurses. A qualitative

study on patients’ experiences of nurse–patient communication confirms this notion partially. Patients

described nurses to be more concerned with completing tasks than talking to them and some patients

were frustrated and felt nurses did not care about them as individuals (McCabe, 2004). However, as our

findings also indicate, nurses were not blamed for this. Our findings show how patients make excuses

or minimize their expectations towards nurses. McCabe (2004) found similar results. Although patients

indicated they would like to be treated as individuals, they did not blame nurses and attributed nurses’

poor communication skills to the idea nurses were ‘too busy’ (McCabe, 2004). Blaming factors outside

of nurses’ responsibility or minimizing expectations towards nurses, is also seen in acutely ill older

patients. Patients ‘managed’ their relationship with nurses by showing concern for the busy, time-

pushed, emotionally exhausted nurses, by being grateful, and by trying to be a ‘good patient’ (Maben et

al., 2012). Maben et al. (2012) posit how this results in a lack of complaint, and satisfaction with care

based on low expectations. As a patient in the study of Maben et al. (2012) explained, ‘she did not want

to be seen as someone who is complaining’. Our finding that patients were inclined to emphasize

satisfaction with care during the first moments of interviews might be a similar finding. Patients adjust

and lower expectations, thus avoiding the need to complain. Stories of transgressive behaviour were

only gradually and cautiously formulated when asked to elaborate on experiences in care relationships.

This finding might show the relative meaning of patient satisfaction surveys. Patients can give positive

evaluations of quality of care while they have negative experiences in healthcare. Consequently, there

are differences between experiences reported in public accounts (for instance in questionnaires) and

those reported in personal accounts (during an interview). Moreover, the process of adjusting

expectations and searching for own solutions for untoward needs, might mitigate or diminish the need

for formal reporting of complaints. Simultaneously, the complex process of perceiving transgressive

behaviour demonstrates how these experiences are not easily articulated as formal complaints as they

are primarily grounded in nurse – patient interactions and dynamics of care relationships.

4.2. | Limitations

A limitation is the cross-sectional design. Patients were interviewed during or shortly after their hospital

admission. A longitudinal approach by interviewing patients multiple times during hospital admissions,

would allow an understanding of how perceptions might alter during hospital admissions. Further

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research could adopt a longitudinal design which would elicit more clearly processes of adapting

cognitions and emotions in interactions with nurses.

5. | Conclusion

We gained an indication on how patients perceive transgressive behaviour and what processes underpin

these perceptions. Patients employ a framework of suppositions when they are admitted to the hospital.

They have certain ideas about professional care in the hospital and personal care relationships with

nurses. Due to patient’s adjustment of behaviour or expectations when assumptions are not met, it is

difficult for nurses to ascertain what problems patients experience. It is crucial that patients feel free to

talk about experienced discrepancies so these experiences might be explained, clarified or resolved. As

a nurse, it is vital to understand that patients might bring negative ‘baggage’ because of previous hospital

experiences. This entails the risk patients are more reluctant to access hospital care, trust nurses’

caregiving or talk about previous negative experiences. The findings also point out how some

expectations are ‘not negotiable’. Patients make efforts to understand and cope with experiencing not

being treated as human beings, but they are indignant when professional caregiving is experienced as

inadequate or of questionable expertise. Professional incompetence in a professional institution as a

hospital is inconceivable. This finding is important for nursing education as it points out interpersonal

communication skills and professional technical competences are both crucial. In addition, this study

shows that even in a topic as transgressive behaviour, usually associated with interpersonal

communication, professional technical nursing competencies cannot be seen as less important.


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Nurses’ perceptions of transgressive behaviour

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Chapter V.

NURSES’ PERCEPTIONS OF TRANSGRESSIVE BEHAVIOUR

IN CARE RELATIONSHIPS WITH PATIENTS

Tina Vandecasteele1,2, Bart Debyser2, Ann Van Hecke1,3, Tineke De Backer2, Dimitri Beeckman1,

Sofie Verhaeghe1,2





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Verhaeghe S. (2015) Nurses’ perceptions of transgressive behaviour in care relationsh ips: a qualitative

study. Journal of Advanced Nursing 71(12), 2786–2798.

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117

Nurses’ perceptions of transgressive behaviour in care relationships: a qualitative

study

ABSTRACT

Aim. To acquire insight into the onset and meaning of transgressive behaviour from the perspective of

nurses.

Background. Patient aggression towards healthcare providers occurs frequently. Nurses in particular

are at risk of encountering aggressive or transgressive behaviour due to the nature, duration and

intensity of care relationships with patients. This study analysed nurses’ perspectives with regard to the

onset and meaning of transgressive patient behaviour in a general hospital setting.

Design. Qualitative research according to the grounded theory method.

Methods. Data were collected in 2011 through individual interviews with 18 nurses who were selected

using purposive and theoretical sampling.

Findings. Findings revealed that various nurse - patient interactions can result in episodes of

transgressive behaviour, depending on the interplay of determining and regulating factors which have

been identified at the patient, nurse and ward level. Experiences of transgressive behaviour are

influenced by the degree of control nurses experience over the provision of care; the degree of patient

acceptance of organizational and ward rules, the degree of gratitude and recognition expressed by the

patient and the extent of patient regard for the nurse as a person. Factors affecting transgressive

experiences were a trusting relationship between the patient and the nurse; the extent to which patient

perspectives are understood; the methods of managing transgressive behaviour; and the influence of

the team, head nurse and ward culture and habits.

Conclusions. The results of this study can support the development of nurses’ coping ability and self-

confidence to mitigate or prevent experiences of transgressive behaviour.

Keywords. Aggression, care relationship, general hospital, nurse–patient relationship, nurses, nursing,

qualitative research, transgressive behaviour, violence.

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1. | Introduction

Patient aggression towards healthcare providers occurs frequently (Hahn et al., 2008; Hahn et al., 2012;

Spector, Zhou, & Che, 2014). Nurses are at especial risk due to the nature, duration and intensity of the

care relationship with patients (Gerberich et al., 2004; Abderhalden et al., 2007; Waschgler et al., 2013).

Reports on prevalence and incidence indicate that high percentages of nurses have been subjected to

patient aggression at some time (Hahn et al., 2012; Spector et al., 2014). Literature suggests there may

be substantial consequences from aggressive encounters, with negative implications for the personal

well-being and professional performance of care providers, patient outcomes and the quality of care

(Needham et al., 2005; Hahn et al., 2008).

1.1. | Background

Although patient aggression has been widely studied in recent decades, most of the research relates to

geriatric (Almvik, Rasmussen, & Woods, 2006; Duxbury, Pulsford, Hadi, & Sykes, 2013), emergency

(Gerdtz et al., 2013) and mental health settings (Abderhalden et al., 2007). Research on aggression in

general hospitals is limited (O’Connell et al., 2000; Wells & Bowers, 2002) and generalizing from specific

to universal settings is difficult.

Research on aggression in healthcare usually reports occurrence of aggression. This is performed by

measuring risk factors associated with patient aggression or violence (Hahn et al., 2010; Hahn et al.,

2013) or by surveys where nurses indicate to what extent they are exposed to specific physical, verbal

and non-verbal behaviours (Foster, Bowers, & Nijman, 2007; Abderhalden et al., 2008, Yang, Spector,

Chang, & Gallant-Roman, 2012). Comparing these results is challenging due to some methodological

and theoretical difficulties. For example, in several studies, the researchers assume that specific

behaviours are perceived as aggressive by definition. However, perceptions of what constitutes an

aggressive act can vary from person to person. There is little insight into how aggression is perceived,

what limits are exceeded for a situation to be experienced as aggressive and which factors influence

this process. Few studies situate aggression in the patient-nurse interaction (Nijman, Bowers, Oud, &

Jansen, 2005) or in relational environments in which aggression takes place. Furthermore, several

articles illustrate the problem of under-reporting of aggressive incidents (Chapman, Styles, Perry, &

Combs, 2010; Gates, Gillespie, & Succop, 2011). This indicates that the aetiology and seriousness of

the phenomenon of aggression is not yet fully understood, making generalizations about the


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phenomenon of aggression in nursing care on general hospital wards difficult. This study attempts to

meet present difficulties in existing literature.

As a first step, an unambiguous operationalization of aggression was necessary. In the literature,

different definitions exist, highlighting different elements of the concept of aggression (Liu, 2004; Nijman

et al., 2005; Liu, Lewis, & Evans, 2013). These elements have been merged into the following broad

definition of aggression: Inflicting harm to material or to another person by transgressing the other

person’s limits, standards or norms. This is expressed by verbal or physical aggression, intimidation, or

threats to objects. This study focused on the “transgressing of limits, standards, or norms”. The concept

of aggression was operationalized using the broader term ‘transgressive behaviour’, since the

perception of an aggressive act is an internal personal construct and varies among individuals

(O’Connell et al., 2000). Use of this term allows an individual interpretation of when and what limits are

exceeded without defining them in advance. In literature, ‘transgression’ is common ly combined with

moral or ethical values or principles as boundaries. However, this conceptualization already presumes

certain moral or ethical suppositions which have to be crossed for a moral of ethical transgression to

occur. In the present study, we did not define or expect particular ethical or moral principles to be at

stake when perceiving transgressive behaviour. We started inductively with exploring the understanding

of what is transgressive and what are underlying processes in this perception. The interpretation of

limits, how they are exceeded, the perceived seriousness of the situation and the processes involved in

this interpretation, were not determined in advance. Furthermore, transgressive behaviour is situated in

the nurse - patient relationship and the nurse – patient interaction. To fully understand this interaction,

both nurses and patients were included in the overall study. The overall aim of the study is to provide a

better understanding of perceptions of transgressive behaviour in care relationships from the

perspective of nurses. This study is part of a larger study where patients were also interviewed regarding

experiences related to transgressive behaviour. These results will be described in another manuscript.

Subsequent combining both perspectives in an integrative analysis will provide an overall perspective

of transgressive behaviour in care relationships.

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2. | The study

2.1. | Aim

This study sought to answer two questions from a nurse’s perspective:

What behaviour in the patient–nurse relationship is perceived as transgressive? and;

What processes or mechanisms influence perceived seriousness of transgressive behaviour?

2.2. | Design

A qualitative study according to the grounded theory with constant comparison was conducted to

understand and explain nurses’ perceptions of transgressive behaviour in care relationships with

patients (Glaser & Strauss, 1967; Morse & Field, 1996; Hallberg, 2006).

2.3. | Sample

Participants were recruited in December 2011. The study was conducted in six wards located in two

general hospitals in Belgium. These hospitals serve both rural and urban communities situated in West

Flanders, a Dutch-speaking Belgian province. Included wards had a diagnostic, medical, geriatric, or

surgical focus. Heads of departments and head nurses were informed about the study. The researchers

informed the nurses about the study aim, the procedure of the study, and talked about the practical

considerations.

A purposive sample of experienced nurses who agreed to participate was selected for variety in age,

educational degree and work experience. This recruitment procedure was designed to lead to situational

diversity in experiences with regard to transgressive behaviour. To broaden initial insights and to select

participants for subsequent interviews, theoretical sampling was used (Draucker, Martsolf,

Ratchneewan, & Rusk, 2007). After nine interviews, further interviews were thus carried out with male

and female nurses from another hospital to assess the influence of hospital culture on perceptions of

transgressive behaviour. Theoretical sampling was also adopted to search for wards with a strict regime

or with a loosely structure to assess the influence of ward organization on perceptions of transgressive

behaviour.

Eighteen nurses were interviewed. Sample size was determined by data saturation, when no further

information was obtained and when connections among emerging concepts were clear. Saturation was

reached after 15 interviews. A subsequent three interviews did not lead to further deepening of the

analysis and as such validated the saturation. Table 1 summarizes the characteristics of the 18 nurses


121

that participated in the study. The sample comprised a range of participants in terms of age, education

and professional nursing experience. It was not possible to identify characteristics of participants who

refused or did not respond to the invitation to take part in the study due to confidentiality issues.

Table 1. Characteristics of the participants.

Nurses (N=18) Nurses (N=18)

Gender (female) 16 Age category (years) Educational 20-30 7

Undergraduate degree 9 30-40 6 Bachelor degree 7 40-50 3 Master’s degree 2 50-60 1

Professional nursing experience (years) 60-70 1 0-5 3 Hospital wards

5-10 7 Neurology & Neurosurgery 4 10-15 4 General internal medicine 2 20-25 1 Oncology 2 25-30 1 Gerontology 2 30-35 2 Cardiology & Pulmonology 4

Neurological & Locomotor rehabilitation

4


All interviews were semi-structured and lasted approximately 40 minutes. Participants were interviewed

in private at the location of their choice, usually in a separate room at their workplace. The interviewers

adopted a conversational and emphatic approach. Each interview started by asking the nurse to

describe an incident that he or she perceived as transgressive. Interview techniques elicited more detail

about these experiences. The main topics discussed were communication with patients, consequences

of incidents, coping, communication with colleagues and general ideas about nursing care and nursing

responsibilities. Table 2 provides examples of frequently asked questions.

As nurses were asked about experiences of patient behaviour, social desirability might account for an

important bias. To address this, an inviting and intimate atmosphere was created while guaranteeing

confidentiality of the interview. This measure contributed to the credibility of the study. Interviews in the

beginning of the study were more open than the later ones as important concepts emerged from the

earlier analyses (Draucker et al., 2007). During and immediately after each interview, the interviewer

made field notes about the nurse’s non-verbal expressions and wrote down initial ideas about the story

of the nurse or his or her own perceptions of the interview. All interviews were tape-recorded. Audio

recordings were transcribed verbatim by a professional transcription service. Identifying data of persons

mentioned in the interviews were deleted. Two analysts checked each transcript against the recording

for accuracy. Hence, they immersed themselves in the data and became sensitive to the issues of

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importance. These analysts uncovered and added important information on reflection about participants’

expressions and reactions.

Table 2. Examples of frequently asked questions.

How do you understand ‘transgressive behaviour’? Can you provide an example?

How did you feel about that incident? What was it like for you?

Can you describe what happened? What did the patient do? What did the patient say? How did you feel

about that reaction? How did you respond?

How did you cope with that experience? What made it difficult? What stimulated you?

How do you look back on that? What was the following day like for you?

What role did your colleagues play for you during this incident? What did you tell them? How did you

tell them? Did they help you through it and how, or did they give you a hard time? Is this something that

you discuss among yourselves? How would you advise a colleague when he/she had the same

experience? What role did the head nurse play?


Approval for the study was received from the local Ethical Commissions. Nurses who agreed to

participate signed an informed consent form, were free to choose the location for the interview and were

advised of their right to withdraw at any time. As nurses were asked about experiences of patients’

behaviour, confidentiality and anonymity were stressed. The researchers were not know to any of the

participants.


All of the interviews were read in full to acquire an overall picture of the interview, then were re-read to

grasp details and to familiarize with the data. Meaningful content of the interviews was described and

coded using the NVIVO soft-ware package (QSR International). Initial open and inductive coding

progressed to axial coding as the analyses progressed. Concepts emerged as the transcripts and codes

were studied and possible meanings of interviews were considered.

2.7. | Rigour

The validity of the analysis increased by incorporating reflexivity and by means of investigator

triangulation. To achieve credibility and conformability, four researchers compared and discussed at

regular intervals the induction of concepts and checked analyses along with acquired data. All the

researchers have experience in conducting qualitative research while one researcher has extensive

experience in conducting grounded theory research. An audit trail was used to capture decisions


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regarding sampling and to describe the structure and rationale of meanings assigned to data, which

strengthened dependability (Lincoln & Guba, 1985). Data collection and data processing were executed

iteratively until data saturation was reached (Charmaz, 2008).

3. | Results

Nurses described and elaborated on diverse incidents in patient contact which were experienced as

transgressive behaviour. Although nurses described different experiences of perceived transgressive

behaviour, the analysis converged around a consistent set of factors that impinged the perception of

transgressive behaviour. Nine factors were identified. These factors work in two distinct manners. Four

factors have an outspoken influence on the onset of the perception of transgressive behaviour

(determining factors), five factors indirectly determined the perceived seriousness of transgressive

behaviour (regulating factors). These nine factors will be described to construct how perceptions of

transgressive behaviour emerge.

3.1. | Determining factors

The first four factors are determining factors. These factors are factors which, at a given moment and in

a particular situation, encompass a limit to be exceeded, causing specific behaviour to be perceived as

transgressive. The following dimensions were identified as determining factors: The degree of control

that nurses experience over the provision of care, the perceived degree of patient acceptance of

organizational and ward rules, the perceived degree of gratitude and recognition expressed by the

patient and the perceived extent of patient regard for the nurse as a person.

The perceived degree of control that nurses experience over the provision of care and perceived

degree of patient acceptance of organizational and ward rules. Nurses regard the role of a good

nurse as providing proper care to patients. Consequently, they consider it their responsibility to ensure

that the patient receives proper care. To achieve this within a limited time frame, nurses feel the need

to control the organization of care.

“…What is it that makes you satisfied about your work? [interviewee]: The feeling that you can

provide the care like you want to provide, because that is not always possible due to lack of

time…”

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Subsequently, the need to control provision of care leads to the expectation of a complementary attitude

from patients and their acceptance of organizational and ward rules. Patient behaviour perceived as

difficult or unpredictable is experienced by nurses as transgressive because it disturbs the performance

of care activities and results in a sense of loss of control over the provision of care:

“…People claim and expect too much. There are things they can do themselves, they call to get

their glasses filled with water and you have to go quickly whilst they can do it themselves…”

“…They expect you to be there immediately because they feel a little pain. You don’t get any

time while we already work so fast. There is no patience. And they expect us to do things they

can do themselves…”

The organizational and ward rules that nurses define as important and use as a framework for the

performance of their care activities, appear to be mostly self-imposed. They are not described as a

prerequisite or as dictated in a ward policy. Nurses describe how they try to maintain a planning of their

provision of care. One nurse described she wanted to finish hygienic patient care by 10 o’clock in the

morning, so she would have time to drink some coffee and subsequently have a quiet moment to fill in

patient files. This planning was not imposed by the ward or the organization. However, when patients

asked something interrupting this self-imposed planning, perceptions of transgressive behaviour

appeared to emerge more rapidly.

The perceived degree of gratitude and recognition expressed by the patient and the perceived

extent of patient regard for the nurse as a person. In their personal interpretation of the care

relationship, nurses expressed a need for implicit and explicit recognition of their personal and

professional roles. Situations were perceived as transgressive when nurses felt undervalued for their

position and expertise:

“…I do my best and the family and patient think, I don’t work enough. I’m not fast enough,

patients are not well cared for, they have to sit up for a long time… While you know you did

everything you could do… That really hurts...”

Several nurses described how they wanted to be seen by patients as a person without being connected

to professional tasks. Caregiving provided nurses a feeling of self-worth and satisfaction, a feeling that

was threatened when patients did not provide confirmation of proper care. Obtaining gratitude and


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recognition from patients can thus be part of the expectation of patient respect for the way nurses provide

care:

“…Particularly the way people state things, it is demeaning: ‘You are paid to do this’…”

“…Sometimes, we do have patients who are grateful. A woman for example said this morning

that we were so kind. That experience is lovely, it makes the whole day better...”

The lack of recognition of the personal and professional role of the nurse was a determining factor for

the onset of perceived transgressive behaviour. Nurses reported that when they did not feel appreciated

in their personal and professional roles, they valued the caring aspect of the relationship to a lesser

degree, distancing themselves from the patient. As a consequence, simply completing the expected

tasks and maintaining control over the provision of care became more important.

3.2. | Regulating factors

Although these determining factors can result in an experience of transgressive behaviour, several

factors regulate the meaning of these experiences. These factors are regulating factors. Regulating

factors reinforce or mitigate a nurse’s experience and the perceived seriousness of transgressive

behaviour. Two levels were identified at which these factors manifest: The nurse level and the

organizational level. At the nurse level, a trusting relationship between patients and nurses, the extent

to which patient perspectives were understood and the way transgressive behaviour was managed,

were directly regulating factors influencing experiences of transgressive behaviour. At the organizational

level, the role of the team and head nurse and the influence of ward culture and habits, were indirectly

regulating factors influencing experiences of transgressive behaviour.

Nurse level – trusting relationship between patients and nurses and the extent to which patient

perspectives are understood. When nurses knew the patient in a more personal way and understood

individual needs, they perceived transgressive behaviour as less serious. The existence of a trusting

relationship mitigated the experience. Likewise, when patient behaviour could be attributed to external

factors, transgressive behaviour was experienced as less serious:

“…You build a band, family members and patients tell you something and you tell something.

By opening yourself up, you experience less transgressive behaviour…”

“…You won’t experience transgressive behaviour of patients when you have a good connection

with them…”

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The existence of a trusting relationship with the patient implies the ability to understand patients’

perspectives and needs. Subsequently, nurses perceived patient behaviour in a contextual manner

which ‘normalized’ the meaning or mitigated the seriousness of potentially transgressive behaviour:

“…To us, 5 minutes is not long, but if you urgently need to go to the toilet and you have to wait

five minutes, I imagine it is absolutely not pleasant…”

Nurse level – the way transgressive behaviour is managed. The way nurses managed experiences

of transgressive behaviour was a third regulating factor. Different methods are employed to prevent or

respond to transgressive behaviour to provide proper care. Nurses had preferred, individual ways of

dealing with transgressive behaviour, which were employed in every situation and not differentiated

according to patients. Nurses who felt they lacked the ability to deal with transgressive behaviour

perceived it as more serious and disturbing. Consequently, coping styles had an impact on the

perception of seriousness of transgressive behaviour. The most common style was to avoid interaction

with the patient. Nurses reported that they knew what they should not do when confronted with

transgressive behaviour, but did not know what they were supposed to do. As a result, they remained

silent, left the room, avoided the patients, or tried not to enter the patient’s room alone:

“…It is creativity. A patient did not want to take his medication and got angry, so I tried to tempt

him with a pudding or a drink. It is a way of avoiding contact about his medication by using

concrete things, in order not to provoke…”

“…She was always angry with us. So I washed her as early as possible so she was still half-

asleep. So by the time she’s fully awake, I was already gone…”

Organizational level – the role of the team and head nurse. The influence of nursing team members

and the head nurse was a regulating factor that mitigated or exacerbated experiences of transgressive

behaviour. Nurses felt supported by venting their experiences with colleagues. Colleagues might look

for solutions or offer to take over care tasks so that the nurse was no longer confronted with

transgressive behaviour. Because of this support, incidents were perceived as less oppressive. Head

nurses were also considered to be in a supportive role since they were perceived as more empowered

to put an end to transgressive behaviour of patients. Support from the team and head nurse took on a

regulating role regarding experiences of transgressive behaviour consistent with the commonly used

method of evading interaction at the nurses’ level:


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“…I did not know what to do. So I went to my colleague and she said she would handle it. So

she addressed the patient and his family…”

Organizational level – influence of ward culture and habits. Ward standards and habits were a

second regulating factor in experiencing transgressive behaviour. In general, nurses tried to avert

transgressive encounters and in wards or organizational settings where a task-oriented approach was

valued, this method of handling transgressive experiences seemed justified. Individual nurse’s

perceptions concerning transgressive behaviour were shaped by and became similar to the perceptions

of other nurses in the same ward, including behaviour perceived as transgressive, aspects influencing

these perceptions and consequences of these perceptions on relationships with patients:

“…So I said it to my colleague and she asked me what I said to the patient. And she responded

saying ‘you were right to act like that, there was no other way’. So I knew I did the right thing…”

Although different wards were included in the study, no influence of the specific ward characteristics

was found on perceptions of transgressive behaviour. However, nurses did seem to adapt their coping

styles to the culture of a particular ward. New nurses who start working on a ward go through a

socialization process where ward culture and habits influenced personal perspectives on transgressive

behaviour and how to deal with it. New nurses even renounced their own, perhaps more effective, coping

styles to adapt to ward habits:

“…Here we can witness this ¨[author’s note: On some wards, nurses’ names could not be

mentioned in patient contact]: ‘I do not say my name,’ we are afraid that we would be held

accountable if something goes wrong. But I do not really understand, how can it hurt somebody

if they were to know my name?...”

“…This patient got sedatives quickly when he was restless. But the reason for his behaviour is

the fact that he is in a hospital. He doesn’t know anybody and sees white aprons. He does not

see that at home. So medication is administered too quickly. But that is common here…”

The process extending throughout this study and connecting these factors, follows a three-phase model.

Chronologically, phase I starts with an incident that may induce an experience of transgressive

behaviour. Four factors determined this perceived exceeding of a limit. The exceeding of a limit is

followed by phase II, ‘Giving meaning to the incident’. In the second phase, nurses acknowledge the

exceeded limit and give meaning to this perception. Five factors regulate the perceived seriousness

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attributed to this perception of the incident. Based on the meaning attributed to the incident, an

experience of transgressive behaviour can emerge. Figure 1 shows this interplay in the process of

perceiving transgressive behaviour.

Figure 1. Phases of perceiving transgressive behaviour.

4. | Discussion

This study identifies specific behaviours in nurse - patient relationships that are perceived as

transgressive and which factors influence perceptions of seriousness. The interviews revealed that

nurses are exposed to different types of behaviour that can be perceived as transgressive. The

interviews also demonstrated that behaviour in itself does not determine ‘what’ is experienced as

transgressive. The qualitative approach of this study allowed exploration of this notion as this type of

research begins with personal experiences of the participants. This analysis revealed experiences of

transgressive behaviour to be associated with both determining and regulating factors. These factors

affect which incidents are perceived as transgressive and what meaning is assigned to them. The

degree of control that nurses have over the provision of care, the degree of patient acceptance of

organizational and ward rules, the degree of gratitude and recognition expressed by the patient and the

extent of patient regard for the nurse as a person were identified as determining factors. As regulating


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factors, the extent of the trusting relationship between patients and nurses, the extent to which the

patient’s perspective is understood and honoured, the way transgressive behaviour is managed by

nurses and the roles of the nursing team and head nurse and ward culture and habits, were identified.

These factors are connected to one another and are responsible for dynamics in maintaining, reinforcing

or decreasing experiences of transgressive behaviour.

4.1. | Interpretation and context of the results

Nurses consider it their duty to provide good care. As a consequence, nurses strive to establish and

maintain control over the provision of care. This striving seems to imply a dedication to finalize tasks

that form a direct requirement for the continuation of care. This striving seems to have two effects. On

the one hand, patients are expected to conform to ward rules and the task division. On the other hand,

more specific nursing tasks or demands (e.g. patient administration, distribution of meals, administration

of medication) are experienced as more important than prevention, recognition, or management of

transgressive behaviour. This task-oriented working context might exacerbate experiences of

transgressive behaviour since transgressive behaviour is a disruptive event interfering with the feeling

of control over the care organization. Previous studies have confirmed this idea, as heavy workloads

and consequent lack of time on the part of nurses can contribute to patient aggression (Zernike &

Sharpe, 1998; Camerino et al., 2008; Morgan et al., 2008). Both factors can reinforce the need for nurses

to feel in control of the provision of care.

Participants reported that their self-esteem was associated with job identity. Lack of confirmation of

professional performance had a negative impact on personal well-being. Similar findings were described

in a qualitative study exploring satisfaction in nursing in the context of staffing shortages. Two of the

intrinsic dimensions of work satisfaction were found to be ‘touching the lives of patients through their

caring work,’ and ‘having pride in acquired skills and competencies’ (Morgan & Lynn, 2009). Nurses

want to feel valued by patients in a personal way and want to be respected for their professional

contribution to patient care at the same time. This finding suggests that dependence on patient

confirmation increases the risk that experiences of transgressive behaviour are perceived more readily

when confirmation is lacking.

Participants in this study responded to experiences of transgressive behaviour with avoidance. A study

on the interpersonal skills that nurses adopt, identified different types of communication styles, including

authoritative interventions (e.g. prescribing, instructing, confronting) and facilitating interventions (e.g.

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catharsis and stimulating reflection, offering support) (Burnard & Morrison, 2005). Nurses in that study

primarily employed authoritative interventions and rarely attempted facilitating interventions (Burnard &

Morrison, 2005). The current study findings are comparable, as participants scarcely used facilitating

communication styles; there were few attempts to understand (the context of) patient behaviours and

the nurse’s own share in incidents was not considered. This might be explained by the way in which

nurses perceive aggressive behaviour. Dunn, Elsom, & Cross (2007) argue that psychological

constructs of self-efficacy and locus of control are closely related to the nurses’ ability to effectively

manage aggressive incidents. Locus of control concerns personal attributions of life events to either

internal or self-directed actions, or to external or environmental factors. In this study, nurse perceptions

of transgressive behaviour might be influenced by their locus of control. Nurses with a strong external

locus of control might believe experiences of transgressive behaviour derive primarily from patient

behaviour and feel victimized because of these experiences. This notion might justify authoritative

interventions. Likewise, nurses with a strong internal locus of control who believe experiences derive

from their own actions, might be inclined to perceive transgressive behaviour as a normal human

reaction arising from a specific interaction. Subsequently, more facilitative interventions might be used.

When there is no catharsis, no exploration or reflection on transgressive behaviour, or when avoidance

is used, it increases the risk that the experience and seriousness of transgressive behaviour will be

amplified.

There is an additional risk that nurses alienate from the patient’s perspective, illustrated by the

identification of a regulating factor: nurse understanding of the patient’s perspective mitigated

perceptions of transgressive behaviour. When patients’ perspectives are not understood, an ‘us and

them’ viewpoint might be adopted, increasing the risk of alienation and perceptions of transgressive

behaviour.

The findings indicate that nurses rarely give feedback to patients on experiences of transgressive

behaviour. Nurses must acquire the appropriate communication skills to do so. Although literature points

out that education and professional experience influence the perceived prevalence of patient and visitor

violence (Estryn-Behar et al., 2008; Hahn et al., 2010; Hahn et al., 2012), present analysis of findings

did not demonstrate a major influence of experience and education on the perception of transgressive

behaviour. However, present findings indicate how the perception of having a ‘good’ way of managing

transgressive behaviour mitigated perceived seriousness of transgressive behaviour. As this is a


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perception, it is not clear whether perceived ‘good’ ways of managing transgressive behaviour is a result

of the professional nursing experience or education.

Supporting language and communication skills of nurses are aspects frequently researched, both on

the level of the individual nurse (Boscart, 2009), and on the level of wards (Björkdahl, Hansebo, &

Palmstierna, 2013; McLaughlin, Pearce, & Trenoweth, 2013). Our findings support the notion to

intervene on the level of the ward since colleagues and ward culture influenced individual nurse’s

perceptions. Together with colleagues, nurses searched for ways to avoid perceived transgressive

behaviour or sought confirmation for their reactions. The team encouraged nurses to vent emotions or

find support in other ways. This finding is consistent with literature (Estryn-Behar et al., 2008; Zeller et

al., 2011).

4.2. | Limitations

There might exist a selection bias in that we only interviewed Dutch-speaking nurses and we recruited

in two large general hospitals. Therefore, we do not know whether our results can be generalized to not

native Dutch-speaking nurses or nurses working in University hospitals.

4.3. | Implications for practice

Present findings reveal self-imposed rules and standards nurses use to plan their own care leading to a

specific expected accepting attitude of patients of this self-imposed care planning. It is important that

head nurses or nurse managers support nurses in making these self-imposed rules or standards more

explicit and support nurses to become more aware of the consequences and risks of these self-imposed

planning. It is also of particular importance that new graduate nurses are vigilantly empowered and

stimulated to reflect on the nurse - patient relationship, understand the patient perspective and provide

patient-oriented care. Literature on the transition process of new graduate nurses to practicing nurses

demonstrates how this is a major challenge (Feng & Tsai, 2012). However, literature suggests that short-

term education sessions where nurses are supported in reflecting on the interaction with patients and

encouraged to understand the patient’s perspective can be sufficient to obtain a reflective and patient-

oriented interaction (Boscart, 2009). Reflecting in group on experiences of transgressive behaviour while

contemplating the interaction with patients, understanding the patient’s behaviour and the regulation of

personal emotions, are interventions described in the mental health setting (Björkdahl et al., 2013) and

the geriatric setting (Zeller et al., 2009). These interventions suggest the importance of intervening on a

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group level when designing programs to support individual nurses. This is important as these

interventions can take the culture of the team and the ward into account. Dackert (2010) reports a

positive relationship between perceived team climate that supports innovation and individual well-being

of nurses and a negative relationship between perceived team climate and stress reactions. A team

climate supporting innovative processes incorporates for example a shared concern about the quality of

work, communication and interaction, the encouragement of nurses to improve their work, etc. (Dackert,

2010). An innovative team climate might imply that nurses are empowered and stimulated to develop

their competences in interacting with patients which might alter and amend nurses’ perceptions of

transgressive behaviour.

Likewise, it would be interesting to examine whether lived experiences of patients and nurses receive

sufficient attention during training and postgraduate courses. For a professional to develop new

competencies, the way of understanding needs to be challenged. Understanding the patient’s

perspective and acknowledging personal feelings and sharing in care relationships, might support

nurses in perceiving and dealing with transgressive behaviour. An increasing tendency to objectify and

standardize nursing care might increase the risk that behaviour in a specific situation is prescribed,

rather than for individuals to evaluate care in a reflective manner.

4.4. | Implications for further research

In this study transgressive behaviour was operationalized based on nurse’s perceptions. Nurses

experienced transgressive behaviour when personal limits, standards, or norms were crossed. No

standard on transgressive or aggressive behaviour was imposed. However, personal boundaries are

different from professional boundaries. Personal experiences of transgressive behaviour do not imply

that professional boundaries are exceeded. However, present findings indicate that nurses’ personal

boundaries coincide with their professional boundaries, whereas a distinction between individual

normativity and professional nursing normativity appears of paramount importance. When personal

limits are crossed, professional limits are not necessarily violated. Future research might explore how

personal and professional standards interact and what professional normativity means for the perception

of the relationship with the patient.

Since colleagues, ward culture and ward habits influenced perception of and reaction to transgressive

behaviour, it would be interesting to examine the effect of individual experiences of transgressive


133

behaviour on staff mentality of transgressive behaviour. Group processes and socialization can be

further explored to design tailored support on a group level for nurses working in general hospital wards.

Likewise, the setting was limited to general medical wards in general hospitals. It would be interesting

to replicate this study in other settings such as residential or home care because in these settings, nurse

interaction with patients and position in relation to patients differs greatly in nature, which could affect

perceptions of transgressive behaviour.

This study revealed dimensions that affect nurse perceptions of transgressive behaviour in general

hospitals. Connecting these findings to the analysis of patients’ interviews will deepen the dynamics of

professional relationships in the context of perceiving transgressive behaviour.

5. | Conclusion

The findings of this study suggest that perceptions of transgressive behaviour are determined and

regulated by several factors on the level of the patient, the individual nurse and the hospital. The findings

demonstrate how nurses’ experiences largely rely on the interaction with patients and thus reveal the

complexity of nurses’ perceptions of transgressive behaviour in care relationships with patients. The

notion that experiences of nurses and patients cannot be separated and contribute equally to

perceptions of transgressive behaviour is a theorem of ‘the interactional model’ (Pervin , 1988, in

Duxbury, 1999). This approach examines violence and aggression in the combined context of both the

individual and their environment and as such recognizes both factors as equally important (Duxbury,

1999). Consequently, if transgressive behaviour can be perceived by nurses as an experience largely

reliant on the interaction with patients, then the care that follows could reflect this approach. Nurses

would thus be inclined to reflect on their own behaviour in the interaction with patients. Present findings

demonstrate how nurses primarily perceive the relationship with and the behaviour of the patient from

their own frame of reference or viewpoint. The specific context or the individual perspective of the patient

is not necessarily inserted in the nurses’ assessment of the interaction with patients, resulting in possible

perceptions of transgressive behaviour. Engaging nurses in ‘reflective practice’ during their working day

might enable them to examine their work and gain insight and awareness from their work. Reflecting on

their work enables nurses to connect with their implicit needs and might challenge them to understand

their patients’ perspectives and experiences (Markey & Farvis, 2014). In turn, implementing ‘reflective

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practice’ can benefit personal and professional development (Williams & Walker, 2003; Gustafsson &

Fagerberg, 2004; Tishelman et al., 2004).


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Influence of team members on perceptions of transgressive behaviour

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Chapter VI.

INFLUENCE OF TEAM MEMBERS ON NURSES’

PERCEPTIONS OF TRANSGRESSIVE BEHAVIOUR

Tina Vandecasteele1,2, Ann Van Hecke1,3, Veerle Duprez1, Dimitri Beeckman1, Bart Debyser2,

Maria Grypdonck1, Sofie Verhaeghe1,2





Based on the article of Vandecasteele T, Van Hecke A, Duprez V, Beeckman D, Debyser B, Grypdonck

M, & Verhaeghe S. The influence of team members on nurses’perceptions of transgressive behaviour

in care relationships: A qualitative study. Journal of Advanced Nursing. 2017;00:1–12.

https://doi.org/10.1111/jan.13315.

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141

The influence of team members on nurses’ perceptions of transgressive behaviour in

care relationships: A qualitative study

ABSTRACT

Aim. The aim of this study was to gain insight into the influence of team members in how nurses

perceive and address patients’ transgressive behaviour.

Background. Aggression and transgressive behaviour in healthcare have been a focus of research

over the past few decades. Most studies have focused on individual nurses’ experiences with

aggression and transgressive behaviour. Literature examining group dynamics in nursing teams and

team members’ interactions in handling patients’ transgressive behaviour is scarce.

Design. Qualitative interview study.

Methods. Seven focus-group interviews and two individual interviews were carried out in 2014-2016.

Twenty-four nurses were drawn from eight wards in three general hospitals. Interviews were analysed

using the constant comparative method influenced by the grounded theory approach.

Findings. While elaborating how they perceived and addressed transgressive behaviour, nurses

disclosed how interactions with team members occurred. Several patterns arose. Nurses talk to one

another, excuse one another, fill in for one another, warn one another and protect and safeguard one

another. In these patterns in reaction to patients’ transgressive behaviour, implicit group norms

transpire, causing nursing teams to acquire their specific identity “as a group”. Consequently, these

informal group norms in nursing teams impinge how nurses feel threatened by patients’ potential

transgressive behaviour; gain protection from the group of nurses and conform to informal ward rules.

Conclusion. The findings of this study can support intervention strategies aimed at supporting nurses

and nursing teams in managing patient aggression and transgressive behaviour by identifying and

explicating these group dynamics and team members’ interactions.

Keywords. Aggression, care relationship, general hospital, nurse–patient relationship, nurses, nursing

teams, qualitative research, transgressive behaviour, violence.

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1. | Introduction

This article addresses the influence of nursing team members on nurses’ perceptions of transgressive

behaviour in care relationships with patients and how they deal with these perceptions. It is imperative

to understand these group dynamics in nursing teams to develop effective organizational interventions

to address transgressive behaviour in care relationships between nurses and patients.

1.2. | Background

Aggression in health care is not a new problem. Aggression towards healthcare workers is prevalent

and well recognized internationally (Wei, Chiou, Chien, & Huang, 2016). The extensive consequences

of aggression in care relationships on nurses, patients, patient care and the organization as a whole,

have induced a large amount of research on aggression in health care. Hence, this research has noted

that aggression is most prevalent in emergency departments, geriatric and mental healthcare settings

(Spector, Zhou, & Che, 2014). Its contributing risk factors have been well documented and have been

identified on the level of patients’ characteristics (Hahn et al., 2013), staff characteristics (Duxbury, 2002;

Jansen, Dassen, & Groot Jebbink, 2005), staff–patient interactions (Winstanley, 2005; Winstanley &

Whittington, 2004) and organizational characteristics (Farrell, Bobrowski, & Bobrowski, 2006; May &

Grubbs, 2002). Much has been learnt about the consequences of encountering aggression regarding

both the physical and psychological well-being of caregivers (Mantzouranis, Fafliora, Bampalis, &

Christopoulou, 2015; Needham, Abderhalden, Halfens, Fischer, & Dassen, 2005) and different

aetiological models on aggression have been described (Duxbury & Whittington, 2005; Wahl, 2009).

This extensive amount of research fosters a greater understanding of aggression in different settings,

patient populations and organizational structures.

However, despite these important insights, some issues regarding aggression in care relationships

remain unclear or under-researched. These issues are related to the specific focus in research on

particular settings and on the perspective of individual caregivers as well as the particular

operationalization of the concept of aggression.

Most studies have focused on geriatric (Almvik, Rasmussen, & Woods, 2006; Duxbury, Pulsford, Hadi,

& Sykes, 2013), emergency (Gerdtz et al., 2013) and mental healthcare settings (Abderhalden et al.,

2007), creating a gap in knowledge about nurses’ experiences in general medical and surgical care

units. However, according to Roche, Diers, Duffield, & Catling-Paull (2010), general hospital settings


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are increasingly regarded to be vulnerable for aggressive incidents (Roche et al., 2010). For instance,

Pich, Hazelton, Sundin, & Kable (2011) identified parents of paediatric patients as a potential significant

group as a source of aggression. Although there have been a few studies focusing on patient aggression

in general hospital settings (Hahn et al., 2013; Heckemann et al., 2015), much can still be learnt about

experiences of nurses working in the former settings (Wei et al., 2016; Winstanley & Whittington, 2004).

Moreover, most studies focus on the perspective of singular nurses on patient aggression (Luck,

Jackson, & Usher, 2008; Stevenson, Jack, O’Mara, & LeGris, 2015). Group dynamics and interactions

with other team members that can influence individual nurse’s experiences are scarcely taken into

consideration (Cox, 2001). Group interactions and the influence of team members can be rather

profound because research on why aggressive incidents are under-reported has noted how peer

pressure from other nursing staff appears to be one of the reasons incidents are not reported (Rippon,

2000; Sato, Wakabayashi, Kiyoshi-Teo, & Fukahori, 2013). This finding suggests that nurses can be

affected or even swayed by colleagues with regards to perceiving, managing or eventually reporting

aggression. Reasons as to why and how nurses are influenced by colleagues, can be partially found in

literature on socializing processes in nursing teams (Bisholt, 2012; Feng & Tsai, 2012; Trysoe,

Hounsgaard, Dohn, & Wagner, 2012). In particular, the concept “professional socialization” (Bisholt,

2012; Mooney, 2007) refers to processes through which new practitioners are merged into the

profession (Mooney, 2007). This process entails that newcomers gradually acquire attitudes, values and

norms of professional clinical practitioners (Feng & Tsai, 2012; Mooney, 2007) while learning (in)formal

rules of the organization (Maben, Latter, & Clark, 2006). These studies focus on experiences of recently

qualified nurses (Bisholt, 2012) or Baccalaureate nursing students (Secrest et al., 2003). It can be

hypothesized that similar processes of socialization remain present in nurses who have been working

for some time in nursing practice (Yarbrough, Martin, Alfred, & McNeill, 2016). Like-wise, it remains

unclear how these processes might influence patient’s care or the conduct towards patients. There is

little knowledge at hand surrounding nurses’ interactions and team dynamics in perceiving and

addressing patients’ transgressive behaviour.

A third issue regarding existing literature on aggression in care relationships pertains to

operationalisations of “aggression”. Several researchers have noted how comparison of research

findings is hampered by adopting different definitions of “aggression” (Hahn et al., 2008; Rippon, 2000).

In addition, addressing related concepts, such as “challenging behaviour” (Almvik et al., 2006) or

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“assault” (Gerberich et al., 2005; May & Grubbs, 2002), made discussions on aggression in healthcare

more thorough and intriguing but at the same time more complex. However, when using definitions of

“aggression”, an assumption that specific behaviours are perceived as aggressive by definition is made.

However, perceptions of what constitutes aggressive acts can vary from person to person. Little insight

is available on how aggression is perceived, what limits must be exceeded for situations to be

experienced as aggressive and which factors might influence this process. In this study, the broader

term “transgressive behaviour” was used because its use allows returning to the “essence” of

experiencing aggression, namely the crossing of one’s limits, standards or norms. Use of this term

allows an individual interpretation of when and what limits are exceeded for situations to be experienced

as transgressive and which factors influence this process. This study strives to use an inductive

approach because the interpretation of limits, how they are exceeded, the perceived seriousness of the

situation and the processes involved in this interpretation were not determined in advance.

Consequently, this study tries to contribute to the literature on aggression in care relationships by

focusing on group dynamics in nursing teams in general hospital settings regarding transgressive

behaviour.

2. | The Study

2.1. | Aim

The purpose of this study was to explore and understand group dynamics and the influence of team

members on how nurses perceive and deal with transgressive behaviour in care relationships with

patients.

2.2. | Design

This study adopted principles of the Grounded Theory to examine reasoning processes used by nurses

for interacting with team members in perceiving and dealing with transgressive patients’ behaviour. This

design facilitated the understanding of nurses’ perceptions regarding complex and potentially sensitive

work-related issues (Glaser & Strauss, 1967; Hallberg, 2006; Morse & Field, 1996).

2.3. | Sample and participants

The study occurred in six hospital wards located in three general hospitals in Belgium. These hospitals

serve both rural and urban communities. Included wards had a medical, geriatric, or surgical focus.

Recruitment and data collection occurred over 2 years from 2014–2016. Study aim and procedures were


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presented to the heads of departments and head nurses. Subsequently, head nurses distributed the

information to potential participants. A purposive sample of nurses who agreed to participate was used,

which enabled diverse perspectives by ensuring participants from different geographic locations, teams

of varying sizes and different care organizations. To deepen initial insights and to bring clarity to evolving

analytical concepts, theoretical sampling was used. After seven focus-group interviews, two individual

interviews were conducted with a novice and a senior nurse to assess the meaning of professional

nursing experience regarding the influence of team members on perceptions of transgressive behaviour.

Table 1. Characteristics of the participants.

Nurses (N=24) Nurses (N=24)

Gender (female) 18 Age category (years) Educational 21-30 7

Undergraduate degree 10 31-40 9 Bachelor degree 12 41-50 3 Master’s degree 2 >50 5

Professional nursing experience (years) Hospital wards

0-5 9 Gerontology 8 6-10 5 Gastroenterology 4 11-20 6 Orthopaedic surgery & Traumatology 6 21-30 2 Neurological & Locomotor rehabilitation 6 >30 2

Twenty-four nurses participated in seven focus-group interviews and two individual interviews. Sample

size was determined by redundancy, when new interviews brought no new information and connections

between emerging concepts were clear (Trotter, 2012). Redundancy was attained after five focus-

groups and two individual interviews. A further two focus-group interviews generated no new insights

and as such confirmed redundancy of data. Table 1 provides an overview of the characteristics of the

nurses who participated in this study. The sample comprises a range of participants in terms of age,

education and professional nursing experience.


Both focus-group and individual semi-structured interviews were conducted by the first author and

another researcher fulfilled the role of observer during the focus-group interviews. To attain reasoning

processes of nurses when interacting with team members regarding transgressive behaviour, principles

of the think-aloud technique were adopted because this technique seeks to reveal mental and cognitive

processes that occur during problem-solving tasks (Funkesson, Anbacken & Ek, 2007). This technique

has been used since the beginning of the 1980s to reveal nurses’ reasoning processes (Benner, 1984;

Simmons, Lanuza, Fonteyn, Hicks, & Holm, 2003). Interpersonal practice scenarios were used to

structure the interviews and prompt the participants to verbalize thoughts, beliefs and decision-making

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in explaining responses to these real-world scenarios. These practice scenarios were collected in a prior

pilot study and provided examples of transgressive patients’ behaviour as experienced by nurses

working in general hospital settings. In addition to these practice scenarios, nurses were encouraged to

recollect own experiences in practice regarding transgressive patients’ behaviour and the meaning of

team members in experiencing or handling this behaviour. As stated in the introduction, “transgressive

behaviour” was not defined in advance prior to the interviews with nurses. The inductive approach

allowed an individual interpretation of when and what limits were exceeded for situations to be

experienced as transgressive. The first scenarios described situations where nurses reflected at a more

individual level on how they would perceive and respond to patient’s transgressive behaviour. Gradually

scenarios were provided which encompassed interactions between team members. Table 2 provides

examples of fragments of interpersonal practice scenarios. Interviews were conducted in a location

convenient to the participants. All the participants chose a separate room at their place of employment,

ensuring their privacy. Focus-group interviews lasted between 65 – 120 minutes and individual

interviews were approximately 60 minutes in length. Field notes were made capturing impressions and

thoughts during and after the interviews, with attention to thick description. During the interviews, these

notes were about that was verbalized, including points that needed clarification. After consent, each

interview was audiotaped. Digital recordings were transcribed to create verbatim accounts. All the

identifiers of the participants were removed from the transcripts prior to analysis.

Table 2. Examples of fragments of interpersonal practice scenarios

“[…] You have to administer an intramuscular injection to a patient. The patients responds by saying

she wants the doctor to administer the injection as ‘you are not competent’[…]”

“[…] You are using the passive patient lift to transfer the patient to his chair. The patient responds by

saying that you are very lazy for using the passive lift […]”

“[…] You are walking in the hallway. You pass a room and witness how a colleague is very rude to a

patient. The response of your colleague provokes an angry reaction of the patient […]”.

“[…] A patient complains about a dirty mobile toilet which was left in his room. It is not the first time

your colleague forgot to remove and clean the mobile toilets. The patient accuses you and says

‘everything is very filthy on this ward’[…]”


Research Ethics Committee approval for the study was obtained from the University Hospital Ethics

Committee prior to commencement. All the participants were given informational leaflets and were

informed of the procedure and objectives of the study. Written consent of every participant was obtained.


147

The participants were assured they could withdraw at any time and confidentiality was stressed. The

researchers were not known to any of the participants.


An iterative approach was undertaken as analysis was performed simultaneously with data collection.

At first, the authors read the transcripts several times to gain an overall picture of the interviews, to

familiarize themselves with the data and to gather initial ideas on the possible meaning of the data. In

search for understanding, probing reflective questions were generated (e.g. in elaborating on

experiences, when do nurses use the term “we” and when do they use the term “I”?) Subsequently,

initial open codes were assigned capturing meaningful content of the interviews using the NVIVO

Software package (QSR International). Without losing the context and attributes of each interview,

constant comparison of interviews allowed the gradual emergence of conceptual insights. Progressively,

more abstract and conceptual insights were constructed and added to these initial understandings. This

approach informed further data collection on theoretical insights and enabled data saturation.

2.7. | Rigour

Several strategies were applied in every phase of the research to ensure trustworthiness of the data

and analysis. The framework of Lincoln and Guba (1985), through the meaning of credibility,

confirmability and dependability, underpinned the study. A thorough form of investigator triangulation

was adopted, ensuring both credibility and dependability of the findings and data (Lincoln & Guba, 1985).

All the researchers had experience in conducting qualitative research and four researchers had

extensive experience in grounded theory research and the thinking-aloud method. The interpretative

process of analysis was underpinned by reflexivity, ensuring openness to the meaning of the data and

a general tenet to question, criticize and explicate understandings of the data (Malterud, 2001). An audit

trail provided a thorough description of the structure and rationale of meaning assigned to data, which

strengthened dependability (Lincoln & Guba, 1985).

3. | Results

During the interviews, nurses explained how they perceived and dealt with transgressive patient

behaviour. Nurses were generally found to prefer a particular way of reacting to transgressive behaviour

and they especially described a rather evasive way of dealing with it. They described how they ignored

transgressive behaviour, how they avoided contact by handing over the patient’s care to colleagues,

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how they limited contact to that was strictly necessary, or how they sought solutions to no longer take

care of the patient themselves.

"...Or not going in alone. We do that very often, entering the room with a colleague. And then

we say: ‘Well, we are going to wash him together right away’. That way we get our work done

faster..."

The interviews demonstrated that nurses are strongly influenced by the interaction with colleagues when

deciding how to address transgressive behaviour. In this interaction, four concrete actions can be

distinguished: (1) talking to colleagues and excusing each other; (2) filling in for each other; (3) informing

and warning each other and (4) defending, protecting and safeguarding each other. These dynamics

will be further elaborated below.

Talking to colleagues and excusing each other (“Tell me what happened… It is not your fault”).

When perceiving transgressive behaviour, nurses approach a colleague. During this first contact, they

usually explain what occurred. They inform their colleague about what the patient said or did. Nurses

mentioned they felt offended and indignant about transgressive behaviour. Communicating with a

colleague served as a form of recuperation. Nurses noted it is very important to communicate with

colleagues to vent or to let go of the incident. Sharing what occurred seems to have a healing effect.

Nurses mainly expected their colleagues to show solidarity. Therefore, it was not necessary to keep on

talking about the incident. Colleagues seemed to adopt an “excusing” attitude. Nurses stated how their

colleagues said they were not to be blamed for the patient’s transgressive behaviour, the incident had

nothing to do with them personally, it was the patient’s fault and they experienced a similar situation

themselves. Because of this “excusing” attitude, nurses did not take the incident personally. Indicating

it was the patient’s fault or noting that other nurses experienced the same thing helped nurses to not

blame themselves.

"...Just tell what the patient said and then that colleague will react ‘Let it be, that’s how that

patient is’, or something similar. ‘That happens a lot and everyone has to deal with that.’ So yes.

‘It also happens to me, so don’t dwell on it’..."

Several nurses noted that it did not matter which colleague they told their story to. They even addressed

colleagues with whom they did not have a good personal bond. Some nurses added that everyone


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knows it is important to let go of the experience at that moment and to talk about it. The bond with the

colleague addressed is of no importance.

"...Nurse 4: I think it is the first person you encounter in the corridor that you. ...// Nurse 3: To

whom you vent. Nurse 4: To whom you can let off steam. Nurse 3: You vent your feelings, and

then the experience is in the past. Nurse 1: Yes, then it’s in the past...."

Talking to colleagues and excusing each other often results in colleagues taking over each other’s care

assignments.

Filling in for each other (“I will take over from you”). Most nurses said they avoided contact with

the patient after they experienced transgressive behaviour. They remarked it would be of no use to

argue or to talk about the problem. They added it would only make matters worse if they were to talk

with the patient about transgressive behaviour. Several nurses said they then handed over care

assignments to colleagues so they either no longer had to see the patient that often, or no longer had

to see them at all.

"...It often happens that someone says ‘Look, I won't enter that room anymore.’ Then someone

else will go. That is the best thing to do. Because eventually you may enter into a discussion

you would rather avoid...”

Furthermore, nurses noted they quickly came to the solution to fill in for each other and to take over

each other’s care assignments. All the nurses said no one has to explain why this arrangement was

made. Filling in for each other is not necessarily further discussed among colleagues. Some nurses said

that this solution is generally believed to be the right one to assure the patient’s care.

"...She kept on shouting, and I said [to a colleague]: ‘You can leave the bathroom, I will carry

on.’ I: And did you discuss that with that colleague afterwards? P: "No, but usually you know

each other well enough. I don’t have to say, I don’t think I should start ‘You should’ve done that

or that.’ I wouldn’t do that"..."

Addressing colleagues about transgressive behaviour and taking over care assignments also results in

fellow nurses being informed and warned about patients.

Informing and warning each other (“You should be on your guard”). Several nurses said that

talking to colleagues about transgressive behaviour allowed them to tell their side of the story. As such,

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colleagues were informed about what occurred in an objective way, nurses said. Some nurses

suggested that the patient himself could indeed tell what occurred to colleagues, which made it important

for nurses to tell their side of the story first.

"...And make clear to your colleagues what happened. If that patient should talk about the

incident to your colleagues... Then your colleagues also know your point of view, what actually

happened..."

When nurses informed their colleagues about patient’s behaviour, these colleagues are warned. That

way, other nurses can prepare themselves when meeting the patient.

“…And if we know that certain people quickly become aggressive or verbally aggressive, we

often say when passing on the patient's care to a colleague: "You have to take extra care with

that patient, be very gentle, because..."

Informing and warning colleagues about patients’ behaviour also led to patients being labelled.

Experiences and impressions of one nurse were shared, which inclined other nurses to adopt the same

judgement. Several nurses stated they already had certain expectations regarding the patient’s

behaviour before actually meeting them.

"...Sometimes, we do influence each other. That’s true. If one nurse says that a patient is a

difficult person, the next colleague who enters the patient's room will often also think he is a

difficult person. 4: "That’s just because it’s passed on like that." 2: "You sometimes think

someone is a difficult person just because you expect them to be difficult. Even though that

might actually not be the case in reality, you start seeing things which indicate that they are

indeed a difficult patient ..." 1: "Yes that’s true. Yes, when you enter the room of a patient your

colleague finds difficult, you will take that expectation into account when you approach the

patient." 2: "Ah, yes" 3: "Yes, you are indeed prepared when you enter the room." 4: "Yes, yes."

3: "You already react differently, don't you?" 2: "Yes you are already ..."//4: "Yes, you can’t

endure that much anymore..."

Labelling patients influenced the concrete contact that nurses subsequently had with the patient. Nurses

said they were already prepared when they entered the room and they were immediately less tolerant

and firmer. They also said they thought in advance about what they would say if the patient was difficult.


151

If nurses adopted a colleague’s judgement on a patient’s behaviour, they seemed to approach the

patient (or their family) the same way their colleague did. Some nurses described how a patient’s

husband interfered too much in the care for his wife. They explained that this man always took care of

his wife at home and he wanted to continue taking care of her in the hospital. These nurses then told

how they, together with their colleagues, made sure the husband did not hinder the patient’s care.

"...Oh, yes. The patient's husband who was intrusive. He always wanted to help and explain to

us how we should do our jobs. Because we also had to place her in the armchair with the hoist,

and then ... <<laughs>>. And then we actually made sure she was already in the armchair when

he arrived. <laughs>> Just to make things easier for us, yes. So he did not ... have to interfere,

you know..."

These implicit agreements on how to approach patients also seemed to have an influence on a fourth

dynamic: defending, protecting and safeguarding each other.

Defending, protecting and safeguarding each other (“You have to protect the team”). When a

patient exhibited transgressive behaviour towards a colleague, all the nurses described how they stood

by their colleague. Nurses quoted several examples of how they witnessed colleagues being insulted or

not knowing how to react to a patient’s reproaches. Most nurses said they joined in the conversation

with the patient and literally stood by their colleague. Several nurses then clarified they wanted to do

this to show they supported their colleague.

"...If I see something is going on ... If a colleague is involved, I’ll immediately go there. I: "And

what would you do then?" P: "First, I’ll ask what’s going on. Then my colleague no longer stands

there alone. ... They [the patients] usually start to falter then. And then you listen to what your

colleague says, and you just agree..."

All the nurses said it was logical and obvious to assist their colleagues. Some nurses added that the

bond with colleagues was of no importance. Even if there was not a good personal bond, it was obvious

to support and defend colleagues when they experienced difficulties.

"...Then you’ll defend that colleague, even if you don’t like them. You’ll defend them anyway. I

do believe we all have it in us. Everyone does it, yes. Actually, we all agree on it? We can all

rely on each other. That's what I feel. No matter what happens... "

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Several nurses referred to incidents where a patient reproached them for a mistake a colleague had

made. All the nurses said they dealt with these reproaches by correcting the situation, soothing the

patient, solving the problem and leaving the situation alone. Then, they usually told the patient they

would immediately solve the problem and that everyone makes mistakes.

"...Say that it was so busy it was forgotten. I would apologize for my colleague and I wouldn't

react to it. 1: "Actually, avoid a discussion with the patient. Just ignore it"..."

All the nurses said they did not further react to the patient’s personal reproaches to express their

displeasure afterwards. They no longer talked about the incident. Some nurses explained they did not

want to talk to patients about a mistake a colleague made. They added that the patient might pass on

what they said about the colleague who made a mistake. They wanted to avoid patients talking to other

colleagues about that.

"...If you think what the patient says about that colleague is true, you do not have to admit it to

the patient. You keep it to yourself. I would certainly not react to it. Because they could use it

against you. They could even ask that particular colleague ‘Do you know what your colleague

says about you?’ You never know. No, no. Hear all, see all, say nothing. That’s what you should

do..."

Furthermore, nurses talked about how they communicated with their colleague when a patient

reproached them for a “mistake” they made. A difference was observed regarding the kind of “mistake”

the colleague made. Nurses described examples of mistakes relating to nursing tasks, for instance,

leaving a bedpan which was not emptied in the room or serving dishes wrongly, as well as mistakes

related to communication with patients, for instance, a patient was berated, or insulted by a nurse. When

the mistake was related to nursing tasks, nurses said they usually used “humour” to talk to a colleague

about that mistake. They made a witty remark or joke about the incident.

"...When I saw her in the corridor, I said ‘Did you forget to remove that bedpan? I will tuck them

in now, okay?’ I said this while laughing. But <<laughs>> Yes, I said that while laughing"..."

Most of the nurses tended to spare colleagues or tried to avoid talking directly about the “mistake”. This

indirect communication was also used for incidents, where a colleague made a “mistake” relating to

communication with patients. Several nurses said especially in those situations it was difficult to talk

about “mistakes” with the colleague involved. Nurses explained that talking to colleagues about mistakes


153

would create tension and this causes problems because they still had to collaborate. Most of the nurses

said they informed the head nurse in such situations and asked them to clear up the incident with the

colleague. Some nurses added it was the head nurse’s task to discuss such matters and as a result,

nurses tended to talk about their experiences with the head nurse instead of with colleagues.

"...I didn’t say that directly to my colleague, but I told the head nurse. I mentioned it in passing

and said: ‘When you have the time, you should talk to that colleague about the incident, to calm

them down.’ If the situation is really delicate, I will speak with my head nurse... "

3.1. | Integration: To what end are these actions towards colleagues directed?

The four abovementioned actions in the interaction with nursing’ team members display an underlying

dynamic. This dynamic will be further explained and clarified in a cyclic process.

A certain vigilance appears to be present in nurses’ dealings with patients. Essentially, perceptions of

transgressive behaviour occur individually with personal contact between the patient and the nurse. As

such, transgressive behaviour is connected to the individual vulnerability of nurses. The nurse feels

insulted, accused or hurt by the transgressive behaviour of the patient. This experience causes the

nurse to search for a colleague to be able to vent, find support and not blame herself, or to let a colleague

fill in for her in providing care for the patient. At the same time, patient’s transgressive behaviour causes

the nurse to feel insulted “as a person” but, simultaneously, feel threatened “as a group of nurses”.

Nurses seem to transfer or picture themselves in two congruent perspectives: their own perspective and

the perspective of the nursing team. Moreover, both perspectives exist in parallel. This means that

experiences of individual nurses virtually “become” experiences of the nursing team which means that

experiences of transgressive behaviour are both shared and transferred. That way, experiences of

colleagues are regarded as each nurse’s very own experiences. Sharing, transferring and adopting

experiences results in the labelling of patients or the adoption of the same kind of approach towards

patients. Simultaneously, it results in nurses self-evidently venting among themselves, self-evidently

excusing one another, self-evidently filling in for one another, informing and warning one another, etc.

Accordingly, in these dynamics, the group of nurses acquires its identity “as a group”. Protecting the

group and subsequently gaining protection of the group, becomes an important implicit focus of

individual nurses; meanwhile protecting and preserving the group becomes a shared unspoken focus of

nursing teams. Protecting the group and putting the group at the forefront also implies that nurses

conform for the sake of preserving the proper functioning of the group. This implies the avoidance of

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mutual tensions and direct criticism regarding performances of colleagues. This important meaning of

the group also influences the way patients are approached. A “we-and-them”-viewpoint seems to be

adopted, where the “we” refers to the group of nurses and the “them” refers to the patients. Adopting

the “we”-perspective induces feelings of protection and trust, which implies that what or who is outside

the group does not induce the same feeling of trust. This feeling of vigilant trust causes behaviour that

might be interpreted as threatening to be interpreted as threatening. The implicit group standard to self-

evidently support one another and interpret and react to transgressive behaviour “as a group of nurses”,

seems to induce a feeling of safety opposed to facing a possible threat from patient contact. Figure 1

shows this process in the interactions between nurses regarding perceptions of transgressive behaviour.

Figure 1. Conceptual model – Process in interactions between nurses regarding perceptions of

transgressive behaviour

4. | Discussion

The findings of this study reveal that dynamics among members of nursing teams influence how nurses

perceive and address transgressive behaviour in care relationships with patients. Four concrete actions

were observed in interactions among nurses regarding patients’ transgressive behaviour. These actions

encompass (1) talking to one another and excusing one another; (2) filling in for one another; (3)

informing and warning one another, and (4) defending, protecting and safeguarding one another. These

actions seem to be underpinned by the motivation to protect the group. The focus on the group is a

perspective that is easily adopted by individual nurses. What follows is an interpretation and discussion

of these findings. The theoretical framework of “professional socialization” (Clouder, 2001) will be

adopted to explicate and contextualize the findings.


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4.1. | Interpretation and discussion of the findings

When nurses encounter transgressive behaviour, they are inclined to approach a colleague to express

their emotions. In addressing the feeling of threat or insult caused by patient’s transgressive behaviour,

nurses seek out a colleague to find support and vent, thus bringing these taxing emotions back to

manageable levels. This example of social coping encompasses the search for social support in solving

problems (Lazarus & Folkman, 1984; Schreuder et al., 2011). Searching social support has been

described in a review on coping strategies of victims of aggression in healthcare (Edward, Ousey,

Warelow, & Lui, 2014). Edward et al. (2014) concluded it is important for nurses to feel safe and

supported when they experience aggression. Present findings confirmed this kind of support is obtained

by interacting with colleagues. In a context of professional socialization, this interaction can be

understood as a form of “attachment” as colleagues represent figures to turn to during times of stress to

find comfort and support, who diminish anxiety (Clouder, 2001). Colleagues respond by telling the nurse

it is not their fault, as she or he did nothing wrong, the patient is to blame or they themselves experienced

similar incidents. However, this kind of interaction induces certain group dynamics and even group

“norms”. For instance, the inclination of nurses to react to transgressive behaviour in a rather evasive

way, is reinforced by easily finding support in interacting with colleagues. While on the other hand, by

excusing and praising one another after transgressive behaviour, colleagues support the evasive way

of handling transgressive behaviour. This interaction induces or maintains a certain professional norm,

asserting it is alright to avoid patients after incidents, not blame oneself, nor feel personally responsible.

Furthermore, a colleague’s approach of self-evidently filling in for another nurse, dismissing and avoiding

exploration of incidents induces a professional norm suggesting it is important not to dwell on such

incidents and to let go of one’s own feelings of vulnerability. Steege and Rainbow (2017) suggest this

interaction might be part of the nursing professional culture because of the value placed on portraying

an image of strength and invulnerability to colleagues and patients. These group norms can also be

understood from a social constructionist perspective on professional socialization as they refer to shared

understandings of what it means to be a professional person (Clouder, 2001). The idea that a nurse

should not react to transgressive behaviour because it may lead to an escalation of the incident seems

to be a shared notion in nursing teams. Communicating with patients about transgressive behaviour is

not considered to be a solution, a finding confirmed in literature (Vandecasteele et al., 2015). Literature

on socializing processes in nursing teams might add to this finding, as appearing to be busy seems to

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be part of the ward culture, while talking to patients is not considered to constitute working (Mooney,

2007). Moreover, the belief that communication can only make things worse suggests an appraisal of

the kind of communication suitable for responding to transgressive behaviour. Burnard and Morrison

(2005) studied different communication styles used by nurses, differentiating between authoritative (i.e.

prescribing, confronting, instructing) and facilitative interventions (catharsis, stimulating reflection,

offering support). Nurses mostly adopted authoritative interventions (Burnard & Morrison, 2005). If

nurses feel most comfortable adopting an authoritative communication style, the belief that

communication about transgressive behaviour can only lead to an escalation appears logical. This

perception might explain why reactions to transgressive behaviour occur as short-term interventions,

that is, avoiding the patient, venting among colleagues, or filling in for one another. These interactions

and the group norms that arise from them, seem to suggest a specific meaning of “the group” for nursing

teams. The need to belong to a team (Secrest, Norwood, & Keatley, 2003), become an insider (Feng &

Tsai 2012), or become accepted in the profession (Bisholt 2012) has been described in literature on

professional socialization. In this study, these needs imply that nurses, on encountering transgressive

behaviour, feel threatened as an individual and at the same time, as a group of nurses. This threat as a

group of nurses generates the adoption of an “us-vs.-them” perspective that reinforces perceptions of

patients as “outsiders” when they display transgressive behaviour. This construction of the “us”

perspective can be a result of the process of socialization into the profession (Clouder, 2001). This

interaction is seen in this study’s findings on labelling of patients. Labels of “difficult patient” were

adopted, shared and transferred. This labelling can suggest a form of moral disengagement (Bandura,

2002), a process which has been studied in the context of nurses (Fida et al., 2016). In Koekkoek,

Hutschemaekers, van Meijel, & Schene (2011), the process of labelling patients as “difficult” is described

in mental healthcare and can be understood in the context of influential research on “the unpopular

patient” (Johnson & Webb, 1995; Stockwell, 1972). Adopting the perspective of the group of nurses and

hence protecting one another, also seems to motivate nurses to conform to informal group rules. For

instance, not criticizing one another regarding interpersonal communication with patients seems to be

an informal rule. This process of conformity is an aspect of professional socialization as internalizing

values and beliefs of members of the profession subjects individuals to social control (Clouder, 2001).

Batch and Windsor (2015) found similar results, as speaking out or reacting in any way other than the

expected manner carried the risk of being identified as a troublemaker and resulted in poor


157

communication among nurses (Batch & Windsor, 2015). Similarly, avoiding one another was identified

as the most commonly used conflict management style of nurses in nursing conflict (Cavanagh, 1991;

Valentine, 2001), a style presumed to maintain harmony and preserve interpersonal relationships

(Valentine, 2001).

4.2. | Implications for policy and practice

It appears imperative that a better understanding and a specific acknowledgement of these team

dynamics might lead organizations to consider these interactions when planning interventions to support

nurses in perceiving and handling transgressive behaviour. Such acknowledgement is important, as

these dynamics presumably have an impact on the quality of patient care. Although these findings were

generated based on nurses’ perspectives, consequences of such team dynamics for patient care can

be hypothesized. Koekkoek et al. (2011) described a tentative model showing how patients and

professionals can reinforce each other’s ineffective behaviour based on their previous attributions and

enter vicious circles of ineffective communication. Similarly, when nurses avoid contact with patients or

label patients, patients might feel frustrated, ignored and hurt, which might cause them to escalate their

behaviour to gain nurses’ attention (Brunero & Lamont, 2010). At the same time, these interactions in

nursing teams include no exploration of what makes transgressive behaviour “understandable” (Stone,

McMillan, & Hazelton, 2015) which increases the risk experiences and seriousness of the transgressive

behaviour will be amplified. As an implication for practice, interventions to support nurses and nursing

teams in processing transgressive behaviour in care relationships should be implemented on a team

level, incorporating the culture of the ward and the dynamics of teams. In the geriatric (Zeller et al.,

2009) and mental healthcare setting (Björkdahl, Hansebo, & Palmstierna, 2013; Bowers, 2014),

initiatives and interventions have been carried out on this group level. Reflecting in group on experiences

of transgressive behaviour while contemplating interactions and communication with patients,

apprehending patient’s behaviour and becoming aware of one’s own implicit personal emotions seem

to be very important in achieving a reflective nursing practice.

4.3. | Study limitations

There were some limitations in relation to data collection. Data collection was limited to individual and

focus-group interviews only. Observations of nursing teams might have generated an additional

understanding of the dynamics of perceiving transgressive behaviour in care relationships with patients,

as it would have provided access to the ways nurses act and interact (Aitken, Marshall, Elliott, &

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McKinley, 2011). However, verbal accounts of nurses proved to provide an in-depth and comprehensive

representation of how nurses perceive and address transgressive behaviour. Similarly, conducting

focus-group interviews allowed to gain tentative access to interactions of nurses in conversing with one

another regarding experiences of transgressive behaviour.

5. | Conclusion

This study complements existing knowledge on nurses’ experiences regarding aggression and

transgressive behaviour in healthcare. The study notes how nurses are influenced by team members in

perceiving and handling patients’ transgressive behaviour. Certain group dynamics and the emergence

of group norms have been identified to impinge these interactions. An important finding of this study

relates to the shared focus among nurses on the protection and preservation of the group. The latter

focus among nurses is underpinned by a process of professional socialization in nursing teams

regarding the conduct towards patients.


159

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General discussion

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General discussion

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Chapter VII.

GENERAL DISCUSSION

Ring the bells that still can ring.

Forget your perfect offering.

There is a crack in everything.

That's how the light gets in.

L. Cohen

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General discussion

167

1. | Introduction

This dissertation addressed how nurses and patients experience the care relationship with one another

in a context of experiencing and perceiving aggression and transgressive behaviour. In addition, the

influence of team members on nurses’ perceptions of aggression and transgressive behaviour was

explored.

This general discussion will start with an introduction on the concept of ‘transgressive behaviour’ as an

important aspect or starting-point in understanding aggression in care relationships. Subsequently,

some key findings of this dissertation will be addressed. Reiterating discussion points of previous

chapters shall be limited to a minimum to avoid duplication. Some reflections on a wider context of care

relationships between nurses and patients will be presented to situate the findings in a broader

perspective. Implications and recommendations for nursing practice and nursing management will be

addressed, and methodological considerations and recommendations for further research will complete

this general discussion.

2. | The merit of adopting the concept of ‘transgressive behaviour’

In the introduction of this dissertation, a distinction between a more objectifying and a subjectifying

approach towards aggression was made. The strongest difference between both approaches lies in the

way aggression is understood and conceptualized. Using an objectifying approach, aggression would

be defined which definition would allow discrimination between that which is aggressive behaviour and

that which is non-aggressive behaviour (Voyer et al., 2005; Hahn et al., 2013; Swain & Gale, 2014).

Whereas a subjectifying approach of aggression tries to take into account the specific context and

assigned meaning of aggression by using the perspectives of the persons involved as starting-points.

In the studies described in chapter II and III, an objectifying approach was adopted in examining nurses’

experiences of patient aggression and aggression by patients’ family members in primary care and in

general hospital settings. Different aspects of aggression in nursing practice were addressed by using

a translated and validated version of the Survey of Violence experienced by Staff (McKenna, 2004;

Hahn et al., 2011). Three manifestations of aggression in nursing practice were explored: verbal

aggression, physical aggression and threats, and in line with other research, these studies emphasized

and stressed how aggression is an important problem and concern for nurses irrespective of their work

setting (Hahn et al., 2013; Spector, Zhou, & Che, 2014; Hanson et al., 2015). In these studies, there

Chapter VII

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was not only a focus on the prevalence and manifestation of aggression, but also on nurses’ perceptions

of aggression and its management. To examine perceptions of aggression, two translated and validated

instruments, the shortened Perception of Aggression Scale (Jansen, Dassen, & Moorer, 1997;

Abderhalden et al., 2002; Needham et al., 2004; Hahn et al., 2011), and the Perception of Importance

of Intervention Skills Scale (Hahn et al., 2011), were used. Based on these instruments, most nurses

were inclined to perceive aggression as a dysfunctional and as an undesirable phenomenon. Several

factors on the level of nurses’ characteristics, nurses’ exposure to aggression, patients’ and family

members’ characteristics, practice characteristics and organisational characteristics were identified to

be associated with nurses’ perceptions of aggression and its management. These different associations

suggest a complicated underlying process in how aggression is perceived as the rationale for some

associations were assumptions in absence of explanatory evidence (Abderhalden et al., 2002). The

objectifying approach towards the concept of aggression was valuable to gain an indication and

description of aggression in care relationships, but restrictive in understanding how perceptions of

aggression occur or take place in interactions with patients or their family members. A critical question

concerns the extent to which a complex and contextually bound concept such as perceptions of

aggression can be operationalized into measurement instruments. The division between perceiving

aggression as a functional or as a dysfunctional phenomenon is too limited, and underestimates the

complexity and contextual dependency of how perceptions of aggression emerge. Consequently, it is

important to enable an understanding of the underlying processes that are present in perceiving

aggression. A more subjectifying approach in trying to understand rather than explain aggression was

found in adopting the concept of transgressive behaviour. This concept allowed an individual

interpretation by both nurses and patients of when and what limits are exceeded in the interaction with

one another without defining these limits in advance. The concept transgressive behaviour emerges

from the different studies as a complex, contextually dependent and relational process in which both

nurses and patients participate in their unique way. All studies point out how behaviour in itself does not

determine ‘what’ is experienced as transgressive. Interviewing nurses and patients concerning their

perceptions of transgressive behaviour, and adopting their representations of their experiences captured

how both nurses and patients give meaning to transgressive behaviour. An underlying process in both

nurses’ and patients’ perceptions of transgressive behaviour emerged and was identified.

General discussion

169

Adopting the concept of transgressive behaviour allowed to address the meaning of transgressive

behaviour from the patient’s perspective (chapter IV). Patients appeared to adopt a framework of

suppositions which generates implicit ideas or assumptions about hospital care and nurse-patient

relationships. Hence, patients envisage receiving competent care and having human interactions with

nurses. These assumptions are implicit, and awareness of these assumptions occurs when patients

experience envisaged care or nurse-patient relationships are not met in their perceived reality.

Experiencing these discrepancies gives rise to a process of adaption, and several patterns are put into

action: patients become more vigilant with regard to care given by nurses; they search for own solutions;

they make excuses for nurses or they reprioritize their expectations. As such, patients go through both

a cognitive and emotional process in adjusting their assumptions or behaviour. Due to these processes,

experiences of transgressive behaviour are put into perspective. The transgressive aspect of

experiencing transgressive behaviour is ‘addressed’ by patients themselves by adopting different

patterns of adjustment.

Subsequently, the onset and meaning of transgressive behaviour from the nurses’ perspective was

explored (chapter V). These findings revealed that nurses’ experiences of transgressive behaviour were

associated with determining and regulating factors. These factors affect which incidents are perceived

as transgressive and what meaning is assigned to them. The degree of control that nurses experience

over the provision of care, the degree of patient acceptance of organizational and ward rules, the degree

of gratitude and recognition expressed by the patient and the extent of patient regard for the nurse as a

person were identified as determining factors. As regulating factors, the extent of a trusting relationship

between patients and nurses, the extent to which the patient’s perspective is understood, the way

transgressive behaviour is managed by nurses and the roles of the nursing team and head nurse and

ward culture and habits, were identified. These different factors appeared to be connected to one

another and were responsible for particular dynamics in maintaining, reinforcing, or decreasing

experiences of transgressive behaviour.

In putting these findings on the nurses’ perspective in a broader perspective, the group dynamics in

nursing teams regarding patients’ transgressive behaviour were examined (chapter VI). Different

patterns of interactions were observed in nursing teams following experiences of transgressive

behaviour: nurses talked to and excused one another; filled in for one another; informed and warned

one another; and defended, protected and safeguarded one another. These patterns in reaction to

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patients’ transgressive behaviour seem to be underpinned by the motivation to protect the group. In

these interactions, implicit group norms transpire, causing nursing teams to acquire their specific identity

“as a group”. These informal group norms in nursing teams appeared to impinge how nurses feel

threatened by patients’ potential transgressive behaviour; gain protection from the group of nurses and

conform to informal ward rules.

These insights into nurses’ and patients’ experiences, and dynamics in nursing teams allowed to obtain

a tentative, but reasonable representation of what occurs in care relationships in a context of

transgressive behaviour. One can question whether these insights render the possibility to formulate a

precise definition of transgressive behaviour as it is customary in research to comprehensively define

the phenomenon under research since a definition can function as a basis for further research and

theory construction (Brüggemann, 2012). Our insights on the concept of transgressive behaviour do not

result in a theoretical definition, nor in an autonomous theory. Our insights make up a theoretical

framework, amenable to modification, which situates transgressive behaviour in a context of care

relationships between nurses and patients. This theoretical framework entails an abstract notion and

understanding of what transgressive behaviour is or constitutes, and this abstract notion of a concept

does induce additional challenges. It can be argued that highly abstract concepts may overlap with other

concepts to a large extent, which makes it difficult to identify the uniqueness of such concepts (Benzein

& Saveman, 1998). For instance, the concept of transgressive behaviour might be expected to overlap

to concepts as abuse (Brüggemann, 2012) and assault (May & Grubbs, 2002; Winstanley & Whittington,

2002; Renwick et al., 2016). However, as Brüggemann (2012) states, trying to obtain uniformity in

defining concepts might dismiss any kind of contradiction or exception which may actually hamper

theoretical development within the field. Therefore it seems to be more interesting to, instead of defining

transgressive behaviour which is an exclusive process, describe transgressive behaviour which is an

inclusive process (Benzein & Saveman, 1998). This approach allowed us in our studies to describe

transgressive behaviour from both the patients’ and nurses’ perspective without defining in advance

what or what not constituted transgressive behaviour. This meant that patients’ and nurses’ experiences

of transgressive behaviour provided the starting-point in our analyses. Because of this -rather inductive-

starting-point, a large diversity was observed in the nature of the experiences of transgressive behaviour

from both the nurses’ and the patients’ perspective. Focusing on specific behaviour that was reported

as an experience of transgressive behaviour would not had rendered an understanding of why and how

General discussion

171

something was experienced as a transgression. As such, it was important to explore the explanatory

underlying processes of how experiences of transgressive behaviour emerge and search for an

understanding of what transgressive behaviour means in care relationships. What follows are some

findings on the connection between the nurses’ and the patients’ perspective in perceiving transgressive

behaviour in care relationships.

3. | Connecting the nurses’ and the patients’ perspective on

transgressive behaviour in care relationships

There are some findings that seem to take on a prominent role from both the nurses’ and the patients’

perspective. These findings pertain to the process of adapting to one’s environment, the importance of

maintaining the organisation of care, and -on a more abstract level- a reciprocal reinforcing process in

nurses’ and patients’ perceptions of transgressive behaviour.

The process of adapting to one’s environment. Findings on nurses’ and patients’ experiences and

perceptions of transgressive behaviour indicate that both nurses and patients appear to adapt or

conform to their specific environment and context. This process of adaptation is characterized by an

alteration of own behaviour or cognitions based on what both patients and nurses experience in their

interactions with others. Consequently, this alteration of behaviour or cognitions presumes an

interpretation of what someone else expects or imposes. Nurses’ perceptions of transgressive behaviour

were shaped by and became similar to the perceptions of other nurses on the same ward, including

patients’ behaviour perceived as transgressive, aspects influencing these perceptions and

consequences of these perceptions on care relationships with patients. Nurses adapted their coping

styles with patient’s transgressive behaviour to the culture of their particular ward. This identified

alteration on the nurses’ level was contextualized in a process of professional socialisation (Clouder,

2001), which entails processes in which nurses adapt to what is common practice in the nursing team

they are part of. Dynamics in the interactions between nurses appear to be underpinned by a shared

focus on the protection and proper functioning of ‘the group’. For the sake of the group, nurses

conformed to implicit group norms and standards.

In addition, the ways in which patients adapted to their environment were quite prominent. Different

patterns were observed, and these patterns display different manners in which patients adapt to their

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context on the nursing ward. Patients adopted a more vigilant, alert and sceptical attitude as an

adaptation or answer to the perception that nurses’ professional competencies were questionable.

When patients encountered untoward needs in contact with nurses during previous hospital admissions,

patients appeared to become more vigilant and stern in subsequent contacts with nurses. On a similar

level, the pattern of finding own solutions is another example of the ways in which patients adapt to their

context. Experiencing untoward needs in contact with nurses entailed this adjustment. They no longer

expected nurses to respond to their specific needs as they themselves already took care of their own.

Another pattern that was observed in patients was the minimizing of expectations and the ‘excusing’

attitude towards nurses. The processes underpinning these patients’ responses to what they experience

in care relationships with nurses, have been acknowledged in literature (Price, 2011; Maben et al., 2012;

McCabe, 2004).

The motives or reasons to adapt to one’s specific environment differ according to the nurses’ and the

patients’ perspective. From the nurses’ perspective, conforming to group norms and standards in the

nursing team ensures they gain protection. Adhering to the common ways of thinking about the conduct

towards patients in a context of transgressive behaviour induces feelings of safety as this conventional

thinking and acting according to the group identity generates a ‘safe haven’ for nurses. In contrast,

patients’ motives to adapt to their specific context appears to be connected to a motivation ‘to weather

through’ the hospital admission. In literature, this process is also described as ‘surviving the hospital

stay’ (Jacelon, 2004). The pattern of establishing priorities in response to untoward needs in contact

with nurses can be understood in this regard. Patients established priorities when both their expectations

to receive competent care and to experience normal human interactions with nurses were not met. As

a consequence, patients judged nurse’s professional competencies to be more important than

interpersonal contacts with nurses. In judging what was worst, patients considered what was most

relevant to them personally, or was most threatening on a personal level. Actively focusing on personal

health as of primary importance in a context of impaired dignity, is recognized in literature (Jacelon,

2004). This particular pattern of minimizing expectations of encountering normal human interactions with

nurses, and focusing on receiving at least adequate professional competencies, was a prominent pattern

observed in the ways in which patients adapt or conform to what they experience during their hospital

admission.

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As part of this process of adapting and conforming to their context, both nurses and patients grew to

focus their attention to the organisation of care.

The importance of maintaining the organisation of care. In exploring both nurses’ and patients’

recollections of transgressive behaviour in care relationships, nurses and patients were found to put the

organisation of care in the foreground. The organisation of care is understood here as the proper

sequence or process of care tasks for all patients on the nursing ward to receive proper care.

Nurses’ considerations start off with the desire to be a ‘good nurse’, a motive that is recognized in

literature (Peter, Simmonds, & Liashenko, 2016). Being a good nurse means that care tasks are finished

in a limited time frame, which brings about a focus in everyday practice on more concrete tasks and the

rather technical side of nurses’ work. Appropriately completing these concrete care tasks seems to be

the nurses’ objective, and the nurses’ framework to assess own performances as a professional person

and as a ‘good nurse’. In this perspective, striving to be a good nurse gives rise to the expectation that

gratitude and recognition is yielded by the patients they care for. Recognition is sought for the proper

completion of care tasks. As such, nurses easily perceived patient’s behaviour as transgressive when

this recognition was lacking. Being interrupted in the execution of care tasks, being told they took too

long to answer patients’ call lights, not being acknowledged in striving to be a good nurse, easily induced

perceptions of patient’s transgressive behaviour. When patients’ recognition for nurses’ professional

role was lacking, which gives rise to a perception of transgressive behaviour, nurses were inclined to

search for recognition and confirmation in the contact with colleagues. In this interaction, colleagues

adopted an excusing attitude towards the nurse and confirmed his or her conduct towards the patient.

Colleagues commonly solved the incident by simply taking over care tasks and filling in for each other.

This solution is easily adopted as nurses seemed to share the focus on the proper completion of care

tasks and the proper maintenance of the organisation of care. The proper organisation of care thus

becomes a shared focus and a justification for their actions. These actions, in simply completing the

expected care tasks with the patient, can also be understood in the ‘we-and-them’-perspective that is

adopted, where the ‘we’ refers to the group of nurses, and the ‘them’ refers to the patients. Because of

this perspective, a focus on the organisation of care is justified, and there is no encouragement to try to

talk to patients about transgressive incidents. Short-term interventions in avoiding the patient, venting

among colleagues and filling in for one another as thus preferred, and a shared focus on the preservation

of the organisation of care is thus shared and consolidated. This approach in nursing teams in solving

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difficult incidents by adopting short-term interventions, might also explain why the majority of nurses

indicated to report none to a few of the aggressive incidents they encountered. The influence of group

dynamics might generate an additional understanding of the reasons why underreporting of aggressive

behaviour is prevalent (Sato et al. 2013).

These identified dynamics in nursing teams appeared to influence the patient’s perspective. As nurses

were focused on the proper organization of care, a conforming attitude of patients and family members

was expected. This meant that patients and family members were expected to conform and adapt to

informal and implicit rules and regulations of the ward and the organisation. As a consequence, patients

were likewise inclined to attach meaning to conforming to these implicit norms and consequently, to the

importance of maintaining the care organization. Finding own solutions and avoiding the need to call the

nurse, being grateful and obliging, minimizing expectations, only calling when it was absolutely

necessary, .. are examples of patients’ behaviour that can be understood in this perspective. As such,

the nurses’ focus on the importance of maintaining the care organisation seems to be shared, and even

imposed upon patients and their family members.

A reciprocal reinforcing process in nurses’ and patients’ perceptions of transgressive

behaviour. The dynamics of adapting to one’s environment, and the focus on maintaining the

organisation of care suggest that nurses’ and patients’ perspectives should not be seen as perspectives

that are constant. Both perspectives are constructed in an interaction between the nurse and the patient;

the nursing team and the nurse; and the nursing team and the patient. This notion comprises well with

the interactional or situational model on the causation of aggression in care relationships (Nijman, 2002;

Duxbury, 2002; Duxbury & Whittington, 2005). Both nurses and patients appear to be responsive and

sensitive to what they experience in interactions with one another, and the underlying processes of

perceiving transgressive behaviour in these interactions were identified. Even though these processes

were studied as separate perspectives, different reinforcing processes in both perspectives seem to be

present. For instance, it can be assumed that the adaptive behaviour in some patients provides an

indirect answer to the nurses’ desire to be in control of the care organisation or the nurses’ focus on the

organisation of care. These patients adopt an excusing attitude towards the nurse, and take into account

the needs of fellow patients or the nurses’ working context in appraising the interaction with nurses. It

can be assumed these patients are also more inclined to be grateful for the nurses’ caregiving as they

are responsive to this need of nurses for implicit and explicit recognition. In contrast, when patients were

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more inclined to be more observant, more stern or more vigilant, it can be assumed their behaviour is

easily perceived as transgressive behaviour. Openly questioning the care they receive, might provoke

nurses to no longer feel in control of the care organisation, which entails the risk that patient’s vigilant

behaviour is easily perceived as transgressive. As such, nurses’ responses might comprise avoidance

of these patients or labelling these patients as ‘difficult’, which in return might provoke a negative cyclic

process wherein perceptions of transgressive behaviour in both perspectives are consolidated.

4. | Care relationships in a broader perspective and challenges for

healthcare practice

Present findings focus on care relationships between nurses and patients. Notwithstanding the particular

interaction between the nurse and the patient, it is important to adopt an ecological -and therefore

broader- perspective acknowledging how experiences of aggression and transgressive behaviour

involve an interaction between the nurse, the patient and the broader context in which this interaction

occurs. This ecological approach comprises well with Paterson, Leadbetter, and Miller (2005)

suggesting a misperception of the problem of aggression as principally a function of interpersonal

conflict. Paterson et al. (2005) argue a recognition of organisational and societal roots of aggression is

important. This encompasses the influence of aspects of the prevalent culture of the ward and

organisation (on a meso-level) and various evolutions in healthcare in specific and society in general

(on a macro-level). What follows is a cursory overview of some contextual aspects and a few reflections

on the presumed influence of these aspects on experiences of aggression and transgressive behaviour

in care relationships between nurses and patients.

On a meso-level, attention is directed towards the culture of the ward and the organisation. The findings

on the group norms in nursing teams highlight how nurses are substantially influenced by the commonly

existing standards among nursing team members regarding aggression and transgressive behaviour.

These group norms influence nurse’s behaviour towards patients and the concrete contact with patients

following perceptions of transgressive behaviour. For instance, easily finding support in interacting with

colleagues reinforces the rather evasive way of individual nurses in handling transgressive behaviour.

Moreover, a colleague’s approach of self-evidently filling in for another nurse, dismissing and avoiding

exploration of incidents induces a certain group norm suggesting it is important not to dwell on incidents

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of transgressive behaviour. In addition, by excusing and praising one another after incidents of

transgressive behaviour, a certain group norm appears to be established that patients are primarily to

blame for perceptions of transgressive behaviour and nurses are not personally responsible. As

mentioned before, being part of this culture of the ward might provoke nurses to adapt to the values,

beliefs, and standards put forth by their nursing team members, processes which can be explicated by

the framework of ‘professional socialisation’ (Clouder, 2001). By focusing on dynamics in nursing teams

regarding patients’ transgressive behaviour (chapter VI), an influence of these dynamics on nurse’s

individual conduct towards patient’s transgressive behaviour was identified. Furthermore, present

findings do not point out that the specificity or the specialisation of the ward, nor the characteristics of

the patient populations admitted to these wards, profoundly influence perceptions of transgressive

behaviour. This is an argument for the transferability of the findings (Lincoln & Guba, 1985) on the

broader dynamics of these influences on this meso-level irrespective of the setting of the general

hospital wards.

The culture of the organisation (the hospital) is also part of this meso-level, which is expected to be

influenced by general evolutions on a macro-level. This macro-level encompasses some broad

developments in society and in healthcare in specific. For instance, there is a global recognition that

hospitals around the world are under tremendous pressure (Karanikolos et al., 2013). This pressure has

to do with the treatment of massively increased volumes of patients, the continuous expansion in size,

the reduction in staffing levels (European federation of Nurses, 2012), the ever-increasing specialisation

of medicine and nursing, the continuous drives for increased productivity and efficiency (Seys et al.,

2017), and the continual pressure to reduce errors (Bargagliotti, 2012), improve patient outcomes (Aiken

et al., 2003; Kane et al., 2007), and quality of care (Mainz, 2003; Ball et al., 2014). Moreover, the contact

time between patients and members of staff has been sharply reduced (Bruyneel et al., 2015), the

average lengths of stay are falling (Buchan, O’ May, & Dussault, 2013), and there is a greater throughput

of patients (Maben, Cornwell, & Sweeney, 2009). In addition, a shortage of nurses is globally recognized

(WHO 2006; Buchan & Aiken, 2008; European Commission, 2012; Bargagliotti, 2012). All these

evolutions pose significant challenges to health systems and governments around the world (Keyko,

Cummings, Yonge, & Wong, 2016). Against this backdrop, different developments on the level of

healthcare institutions and on a societal level have been observed which influence the delivering of

nursing care and the nature of care relationships between nurses and patients. Just a few of these

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developments are the evolution of quality monitoring and quality assessment (O’Reilly, Courtney, &

Edwards, 2007), the digital revolution (Maben et al., 2009; Desmet, 2009), and the audit culture which

is linked to the digital revolution (Maben et al., 2009). In many ways, these developments bring benefit

in producing vastly increased transparency in medical affairs generally (Maben et al., 2009), or by

providing individual facilities with reports indicating their progress in terms of clinical care benchmarks,

enabling them to determine areas for attention in their quality improvement cycles (O’Reilly et al., 2007).

However, these evolutions encompass an inherent focus on the measurability of quality of care or

caregivers’ performance. And even though it is acknowledged that quality of care is not easily defined

nor measured (Donabedian 1988; Marquis, 2002; Mor, Angelelli, Gifford, Morris, & Moore, 2003), the

risk arises that measurable activities in caregiving are privileged over non-measurable activities (Maben

et al., 2009). Moreover, the caring part of nursing, comprising the ‘whole’ package of activities that

include technical and emotional competence, demonstrated interest, giving comfort, and the

acknowledgement of vulnerability (Corbin, 2008), comprehends non-measurable activities. Maben

(2008) hypothesizes this caring part of nursing might become marginalized and subordinated in an

increasingly managerial discourse in healthcare focusing on outcome evaluations and benchmarking.

As such, the focus on standardised organisational practices can have a profound impact on the nature

of nurses’ caregiving (Ranking & Campbell, 2006). It can be hypothesised the ‘caring part’ of nursing is

particularly important in a context of aggression and transgressive behaviour in care relationships.

Although the findings of this dissertation cannot support decided statements on the influence of these

processes on nurse-patient care relationships, it can be assumed that these processes are part of a

larger context affecting the way nurses’ caregiving is constructed or expected to be performed. The

findings on the importance of maintaining the care organisation (chapter V and VI), and the patients’

assessment of the importance nurses attach to guidelines and protocols (chapter IV) can be put in this

perspective. As a consequence, it can be hypothesized that behaviour of some patients is easily

perceived as transgressive because their needs and requirements fir poorly with services available to

them. For example, patients with a chronic illness, patients with multi-comorbities, older patients, etc.

might be easily seen as ‘difficult’ or challenging patients because of the complexity of their essential

requirements and the idea they do not easily fit in standardized organisational practices. As such, these

developments on a meso- and macro-level might increase the risk that more depersonalised or detached

nurse-patient relationships transpire. This presumed remoteness (distance) in care relationships can

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lead to the situation wherein patients are no longer personally known or understood by nurses, which

carries the additional risk that patient’s behaviour is easily perceived as transgressive behaviour.

In considering the effects of these evolutions on nurses themselves, Maben (2008) and Corbin (2008)

point out the difference between how nurses ideally would like to care for patients, and the reality they

face in practice. Restrictions in their care context might induce nurses to feel they are being limited or

constrained in their caregiving, which can result in nurses feeling powerless, burnt-out, frustrated or

morally distressed (Maben, 2008). ‘Moral distress’ is understood as ‘failing to convert personal ideas on

what good care is, into practice’, and can arise when caregivers know what would be the right thing to

do, but experience restrictions to act according to their notion of the right thing to do (Vanlaere &

Burggrave, 2014). In addition to aforementioned restrictions in care organisations, present findings on

group norms in nursing teams also suggest that nurses might feel restricted based on what is common

practice in their nursing team. Even though nurses knew what would be the right thing to do, they

adapted to certain ward habits and renounced their own ideas on handling patient’s transgressive

behaviour. As such, it can be hypothesized that adhering to specific group norms in addressing patient’s

transgressive behaviour might also induce a form of moral distress in nurses. Alongside moral distress,

‘burnouts’ in nursing have also been mentioned as a result of the inability to give perceived ideal care

(Aiken, Clarke, Cheung, Sloane, & Silber, 2002; Reeves, West & Baron, 2005). Burnouts, which

components are emotional exhaustion, depersonalization and reduced personal accomplishment

(Maslach & Jackson, 1986), have been studied in relation to workplace aggression in hospital staff

(Winstanley & Whittington, 2002), suggesting how aggressive encounters were likely to lead to elevated

levels of emotional exhaustion, subsequently causing an increase in depersonalization (Winstanley &

Whittington, 2002). However, elevated levels of burnout originating from workload or other workplace

conditions might also result in staff being more vulnerable to encounter aggression (Winstanley &

Whittington, 2002). Present findings on transgressive behaviour in care relationships appear to suggest

a similar association between experiences of transgressive behaviour and the components of burnouts.

As perceiving patient’s behaviour as transgressive appeared to generate a depersonalised attitude of

nurses, and an emotional remoteness towards the patient. However, it can also be hypothesized that

restrictive working climates, and possible moral distress or burnout as a result, make nurses more prone

or vulnerable to experience and perceive transgressive behaviour in care relationships with patients.

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5. | Implications and recommendations for nursing practice

Translating research findings into clear-cut implications for nursing practice is difficult. Present findings

highlight the complexity of experiencing transgressive behaviour in care relationships between nurses

and patients, which entail a likewise complex solution or answer as to what can be ‘done’ about

(perceptions of) aggressive or transgressive behaviour in care relationships. What follows are basic

principles to consider in addressing transgressive behaviour in care relationships between nurses and

patients. Far from being in any way prescriptive, these basic principles should be considered a basic

reference tool for stimulating the development of interventions or initiatives to aid nurses in (1) reflecting

on perceptions of transgressive behaviour, (2) addressing personal feelings of discomfort based on

perceptions of transgressive behaviour, (3) communicating with patients about perceptions of

transgressive behaviour, and (4) adopting a reflexive stance towards transgressive behaviour in nursing

teams.

Reflecting on perceptions of transgressive behaviour. How nurses perceive transgressive

behaviour made up the starting point of the research. This starting point is important to consider as it

holds the straightforward premise that perceptions of transgressive behaviour are ‘perceptions’ of one

person interpreting certain behaviour or certain words of another person as ‘transgressive’. Hence, it is

important that nurses acknowledge that what they perceive as transgressive is in fact a perception, and

not a given situation. Subsequently, reflecting on own perceptions of transgressive behaviour, how those

perceptions emerge and how own vulnerabilities might impinge these perceptions, is important. As a

nurse, it is of vital importance to recognize the unique disposition and trajectory of patients. This implies

that nurses should recognize that patient’s values and beliefs might differ significantly from the nurse’s

values and beliefs. In this context, the need to be person-centred and compassionate as caregivers is

of foundational importance, and has always followed a parallel stream when historically treatment and

patient caregiving has been institutionalized (O’Toole & Welt, 1989; Koene, Grypdonck, Rodenbach,

and Windey, 1988; Van Heijst, 2006). Person-centred care is defined as the recognition of “the patient

as the source of control and full partner in providing compassionate and coordinated care based on

respect for patient's preferences, values, and needs” (Cronenwett et al., 2007). Person-centred care

requires that nurses value and respect the patient's perspective as well as recognize and explore their

own values (Lusk & Fater, 2013). Further, literature suggests that person-centred care requires nurses

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to individualize care, encourage patient autonomy, and display a caring attitude through therapeutic

communication and respect for uniqueness (Lusk & Fater, 2013). In this description of what person-

centred care entails, three major points are important in the context of transgressive behaviour in care

relationships. First, the necessity of understanding the patients’ frame of reference or context. When

patient’s behaviour is perceived as aggressive or transgressive, it is important to position specific

behaviour in the context of the patient’s illness, illness trajectory or biography in general. It seems

elementary to keep in mind that patients have developed a lot of experience, narratives and skills to

cope with situations throughout their lives. These strategies also influence the way they deal with their

illness or their hospital admission. As such, if patient’s behaviour is perceived as aggressive or

transgressive, it is important see ‘beyond’ specific behaviour. Second, it is important that nurses are

sensitive and responsive to patients in exploring what it is like for them to be in the hospital, what is it

like for them to communicate and interact with caregivers, and how patients give meaning to their

experiences in the hospital. As patients adopted different strategies to adapt to their circumstances in

the hospital, it appears to be of paramount importance that nurses are accessible and willing to listen

more closely to what patients are going through. Third, the notion that nurses need to recognize and

explore their own values and beliefs. As such, the expressed need for patients to be grateful and obliging

could be recognized and dealt with by nurses. Reflecting on these implicit needs, and the consequences

when these needs are not gratified ought be addressed in nurse’s reflective practice (Markey & Farvis,

2014; Williams & Walker, 2003; Gustafsson & Fagerberg, 2004; Tishelman et al., 2004). In addition, a

critical point needs to be raised concerning the difference between personal normativity and professional

normativity. Nurses need to acknowledge the additional risks in avoiding the patient following

perceptions of transgressive behaviour, or ‘getting the work done faster’ by bringing in another colleague

to finish the patient’s care. These ways of coping with patient’s transgressive behaviour encompass the

risk that specific essential signals, symptoms or signs of patient’s distress, patient’s illness, or patient’s

general condition are not noticed or observed. Moreover, according to the patient’s perspective, some

patients are inclined to search for own solutions, like bringing their own pain medication to the hospital

when they do not get their pain medication fast enough, helping other patients get up when nurses take

too long to answer call lights, etc. encompassing an additional risk that important aspects of patient’s

care are not known to or observed by nurses. These examples refer to the importance of the difference

between personal normativity and professional nursing normativity. When personal limits, standards or

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norms are crossed, professional limits are not necessarily violated. However, when nurses were inclined

to avoid patients following perceptions of transgressive behaviour, it can be assumed nurses no longer

succeed at that time in acting as a professional nurse. This distinction between personal and

professional normativity is important to acknowledge and recognize for nurses in reflecting on

perceptions of transgressive behaviour. That way, nurses can perceive transgressive behaviour,

recognize the tendency to avoid the patient as a consequence, and realize additional risks emerge when

patients are avoided. ‘Risks’ can be understood here as potential harm to the integral patient. As such,

avoiding patients following transgressive behaviour would not be recognized as behaviour fitting the role

of a professional nurse. Subsequently, the challenge or task arises to maintain good professional care

irrespective of perceiving patient’s behaviour as transgressive. However, this nurses’ task is demanding

as it involves the emotional labour of managing both personal and patient’s emotions (Delgado, Upton,

Ranse, Furness, & Foster, 2017).

Addressing personal feelings of discomfort based on perceptions of transgressive behaviour.

When nurses perceived patients’ transgressive behaviour, they felt insulted, accused, threatened, hurt,

and even angry. Although nurses were inclined to seek rapid solutions for these feelings by avoiding the

patient, by focusing on completing expected care tasks, or by contacting and ventilating their emotions

among colleagues, it seems to be imperative that nurses acknowledge these taxing emotions, address

them, and try to accept them. When these emotions are accepted and acknowledged, nurses gain an

option on how they care to process or deal with these feelings (Vanlaere & Burggraeve, 2014). A first

normalisation of experiencing these taxing emotions appears to be important. Caregiving entails an

intersubjective interaction, rather than an interaction between an object and a subject (Van Heijst, 2006).

This notion encompasses an acknowledgement of the personal vulnerability and fallibility of caregivers,

and as such, the recognition that it is normal that feelings of irritation or anger transpire in situations in

which different people interact and work together. Feeling irritated or angry might even be a form of self-

preservation, in the sense that own limits or boundaries are preserved and defended (Vanlaere &

Burggraeve, 2014). As such, acknowledging taxing emotions, and exploring how and why specific

interactions with patients are hurtful or distressing, appears to be of particular importance when an

individual nurse perceives transgressive behaviour. The installed group norm not to dwell on incidents,

to let go of incidents, and to let it pass entails the risk that nurses who feel hurt by perceived

transgressive behaviour, feel more alone or more vulnerable. Steege and Rainbow (2016) use the

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metaphor of the ‘cloak of invulnerability’ as a way of referring to the nursing professional culture of

putting value on portraying an image of strength and invulnerability to colleagues and to patients. As

such, the risk arises that nurses might be inclined to cover up frustrations or concerns out of fear of

being judged by their nursing team members as too sensitive or not relentless enough (Roose, 2015).

In exploring how nurses deal with the emotional labour that is part of nurse-patient/family and collegial

interpersonal interactions, Delgado et al. (2017) focused on the concept of ‘resilience’. Resilience in

nursing has been identified as a personal capacity that aids nurses in dealing with workplace adversity

and demands (Hart, Brannan, & De Chesnay, 2014; McDonald, Jackson, Wilkes, & Vickers, 2013), and

is understood as the ability of individuals to bounce back or to cope successfully despite adverse

circumstances (Rutter, 2008; Hart et al., 2014). Building nurses’ resilience has potential to strengthen

their capacity to address the effects of emotional labour on their well-being and work (McDonald,

Jackson, Wilkes, & Vickers, 2012; 2016; Sorensen and Iedema, 2009), and consequently, exploring

possibilities to strengthen nurses’ resilience appears to be important in a context of aggressive and

transgressive behaviour. Furthermore, professing personal vulnerability as a nurse might also create

sensitivity for the vulnerability of the patient. A sensitivity that is part of the Human Condition (Arendt

1998), and part of the ethics of caregiving (Van Heijst 2005). As mentioned before, indirect forms of

relief were used to deal with difficult emotions in contact with patients following perceptions of

transgressive behaviour. Acknowledging the own use of indirect forms of relief, might be constructive to

realise that patients might also adopt indirect forms of relief to deal with difficult emotions. This indirect

relief of emotions might transpire or appear in aggressive or transgressive behaviour of patients. This

realisation might prove to be important in the subsequent contact with the patient following perceptions

of aggressive or transgressive behaviour.

Communicating with patients about perceptions of transgressive behaviour. Following the

previous important principles of reflecting on own perceptions of transgressive behaviour, and

addressing personal feelings of discomfort following perceptions of transgressive behaviour, there is a

subsequent principle of communicating about perceptions of transgressive behaviour. When nurses

perceived transgressive behaviour, communication with patients about the nurse’s perceptions was

avoided. Nurses even narrated that things definitely would get worse if they were to talk about

perceptions of transgressive behaviour with patients themselves. Nurses pointed out how some things

are better left unsaid. This attitude to avoid communication with patients about transgressive behaviour

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appeared to be self-evident and logical, and particularly common among nursing team members. The

observed stance and notion of nurses towards communication about transgressive behaviour can be

contrasted with general guidelines in addressing aggressive patient’s behaviour. Some principles of

treatment protocols of aggression in a hospital setting can be transferred to a context of transgressive

behaviour. An important principle is the notion that aggression ought to be understood as a form of

communication (Audenaert, Meesen, Jannes, & Van Heeringen, 2001). Patients might want to pose an

awkwardly worded question or adopt a rather negative, prominent or harsh way of conveying the

message that something might be wrong or difficult for them. As such, interpreting patients’ behaviour

or patients’ words as ‘merely’ difficult or transgressive or as ‘merely’ harsh words is not enough. An

interpretation as such does not render the possibility to find a connection to the reason why the patient

expresses a certain something in a certain way. Consequently, rather than avoiding communication

following perceptions of transgressive behaviour, an attitude should be adopted showing that the

message (the patient might want to convey) is understood. As such, in perceiving patient’s behaviour

as transgressive, it is important to try to understand how the patient experiences and gives meaning to

his/her specific situation, and to establish whether the patient’s context includes anxiety-provoking

experiences in the eyes of the patient (Winstanley, 2005). As a nurse, it is important to be able to move

beyond literal words or behaviour in order to explore and understand which message the patient wants

to convey. This notion is of particular importance in caring for patients with cognitive problems, such as

Alzheimer’s disease. Looking beyond actual behaviour, being attentive, and trying to correctly interpret

and understand (non)verbal communication and signals (Gaydos, 2005; Steeman, 2013; Grypdonck &

Sermeus, 2016) is a first and crucial step in caring for this vulnerable patient group. When patient’s

behaviour is perceived as transgressive, it is more challenging but ever so important to listen more

closely to the message the patient might want to convey (Gaydos, 2005). If the patients notices that his

or her message is conveyed to the nurse, even though harsh, impolite or vulgar words were used, then

an openness to create a mutual understanding between the nurse and the patient might be triggered

(Keirse, 2014).

Adopting a reflexive and flexible stance in nursing teams in addressing transgressive behaviour.

In addressing perceptions and experiences of transgressive behaviour, nurses were strongly influenced

by their nursing team members. Nurses’ tendency to find support by discussing incidents with primarily

colleagues was also apparent in chapter II when nurses were asked to indicate their primary support

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mechanism when aggressive incidents occur. Consequently, it is important to devise initiatives in

handling patients’ transgressive behaviour on the level of the ward or the nursing team. The findings

suggested there is a common ‘language’ among nurses team members, a language that appears to

connect nurses. Focusing on the proper completing of care tasks, and on the organisation of care

emerges as this shared and consolidated focus among nursing team members. This should encourage

nurses to consider the impact of this shared focus. And this focus also appears to generate certain

implicit rules in nursing teams which need explicitating. As an example, in focusing on the importance

of the organisation of care, Jukema (2011) questions in a context of ‘preservative care’ whether it is

more important that the ‘work’ is finished by 10 o’clock, or that the patients are left in charge of their own

care and decide themselves when they want to be washed? This is simply a tentative example of

considerations that can be made on the level of a nursing team. To extend this example on the

necessary considerations regarding the impact of care organisation, Winstanley and Whittington’s study

(2004) focused on situational variables and patient cognitions in studying patient aggression. They

conclude that the extent to which the encroachment upon patients’ autonomy is seen as anxiety-

provoking by the patient -illustrating how seemingly minor issues such as the timing of personal care-

can be perceived as provocative, which can lead to patient aggression. For instance, not all patients

want to be washed exactly when nurses’ work schedules dictate (Winstanley, 2005). However, it nurses

primarily focus on completing care tasks, this very focus on the organisation of care might induce

aggressive and transgressive behaviour. These policies can be reviewed to determine in what way is it

possible to accommodate the meaning of compassionate care, holistic care, or patient-centered care,

in an organisational structure and context structuring and dictating how, when and in what way service

deliveries (like basic hygienic care) take place (Barclay, 2016). Adopting a flexible and reflexive stance

as a nursing team might make nurses more aware of the patient’s perspective (Dierckx de Casterlé,

2015) which would enable them to take into account patient’s experiences and difficulties, possibly

leading to a reduction in perceptions of transgressive behaviour or possible conflicts. Moreover, terms

and concepts as holistic care, compassionate care (Maben et al., 2009; Blomberg, Griffiths, Wengström,

May, & Bridges, 2016), person-centred care (McCormack et al., 2015; Dewing & McCormack, 2017), ..

are terms that most nurses are familiar with, and these terms are often used or referred to in nursing

practice and nursing education (Maben et al., 2009). Even though these concepts can transpire in

everyday practical acts and decisions (Molewijk & Widdershoven, 2006), the implication and translation

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of these concepts into nursing practice can be quite challenging and difficult. In the nursing team, it

would be quite interesting to discuss, compare and reflect on the meaning of these concepts in everyday

nursing practice. Disagreement in understandings may produce fertile ground for reflective progress. As

such, moral case deliberations (Molewijk & Widdershoven, 2006) could offer possibilities to configure

these discussions since the own (moral) expertise of healthcare professionals forms the starting-point

of these discussions. This would appear to be an interesting focus for nurse specialists in adopting a

role of clinical leader in guiding nurses and nursing teams in these discussions (Hamric, Spross &

Hanson 2005). Moreover, these kind of discussions and reflections are of particular importance in a

context of aggression and transgressive behaviour in care relationships as the translation of these

concepts into practice will be particularly ‘challenging’ when nurses (or nursing teams) feel threatened,

hurt, or insulted by the perception of aggressive or transgressive behaviour. Facilitating reflective

practice in nursing teams might be interesting. In posing different statements regarding what aggression

is or entails, the POAS-s might provide a good starting-point or outline to support this reflective practice.

The different statements - f.i. ‘aggression is to hurt other mentally or physically’, ‘aggression helps the

healthcare staff to see the patient from another point of view’, or ‘aggression is the start of a positive

staff – patient relationship’ – display different cognitions towards aggression, which can prove to be a

good starting-point for discussions among team members. In nursing teams, experiences of aggression

and transgressive behaviour might be deconstructed and explored, which would enable nurses to

identify and consider different perspectives (the perspective of the patient, his/her family, the nurse, etc.)

which might reduce elements of subjectivity (Williams & Walker, 2003). Individual nurses and nursing

teams should be encouraged to examine experiences of aggression and transgressive behaviour and

the impact of management approaches employed. For example, if nursing teams do not reflect on

perceptions of transgressive behaviour, or disregard the patient’s context, the patient’s illness or their

own share in incidents, the strategies employed will not address the problem. As such, the risk emerges

that care may be given with the best of intentions by the nurse, but in real terms may not suit the patient

at all. In other words, the very perception of patient’s transgressive behaviour might emphasize the

‘difference’ between nurse’s values and beliefs and the patient’s values and beliefs, and this difference

in itself should encourage communication between nurses and patients so that nurses can correctly

interpret and understand (non)verbal communication or signals of patients.

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6. | Recommendations for management

Considering management and policies towards aggression and transgressive behaviour in healthcare,

it is important to name the ‘zero tolerance’-policy towards aggression in healthcare, which was adopted

in 1999 by the UK Government’s Department of Health (Whittington, 2002) and to some degree in some

Australian states (Holmes, 2006) to tackle aggression and violence to healthcare staff. A policy of ‘zero

tolerance’ entails that specific behaviour, like aggression, will not be tolerated under any circumstances,

and that there will be a non-negotiable sanction imposed whenever that behaviour occurs (Holmes,

2006). The policy of ‘zero tolerance’ might even entail a red card system where staff issues red cards

when patients’ behaviour is unacceptable encompassing the right to withhold treatment from aggressive

patients. This is but one -albeit rather extreme- example of a hardened attitude, and consequently a

policy, towards patient aggression in healthcare. This ‘zero tolerance’-policy can be criticized based on

present findings, and has been strongly criticized throughout literature. The policy of ‘zero tolerance’

does not allow for consideration of particular circumstances or the motivations of the patient, nor the

nurse interpreting or perceiving specific behaviour. Furthermore, blame is attributed to patients,

intolerance by healthcare workers is encouraged (Duxbury & Whittington, 2005, Paterson et al., 2005;

Holmes, 2006), the complexity of the issue of aggression is ignored (Brockmann, 2002), and the

opportunity to build rapport and understand patients’ emotional needs is hindered (Farrell & Salmon,

2014). Contemplating about policies on and management of aggression and transgressive behaviour in

healthcare is important as present findings suggest that the work environment and context are key to

good nurse and patient experiences. Based on present findings, some considerations for (nursing)

management can be formulated.

The dynamic that was observed in nursing teams in protecting and safeguarding ‘the group’ of nurses

warrants further attention. These dynamics in the interprofessional relationships of nurses was assumed

to be a consequence of the interactions with patients and the perceptions of patient’s transgressive

behaviour that occur in this interaction. Literature suggests however that this dynamic might also be

linked to nurse managers’ reactions when aggressive or transgressive behaviour of patients is brought

up or reported. It is possible that nurses perceived nursing managers to take the patient’s side and

favour customer friendliness over staff protection (Renker, Scribner, & Huff, 2015; Gates et al., 2011).

Even though the interaction between nurses and nursing managers on the topic of patient aggression

or transgressive behaviour was not studied, it is plausible that nurses in the present studies also

General discussion

187

experienced it that way. As such, searching for and receiving protection from the group of nurses might

gain its particular importance as the group becomes the primary source of support. As a consequence

for nursing managers, creating and conserving a supporting climate which fosters open dialogue

between nurse managers of all levels and nursing staff to share and discuss mutual expectations and

support needs seems to be important (Heckemann et al., 2017).

Another recommendation for (nursing) management pertains to the finding that nurses expected patients

to display a form of gratitude and recognition from patients and their families. As a nurse manager, it is

important to acknowledge and identify this need, and encourage practice wherein nurses feel valued by

the organization in which they work (Maben, 2008). Gaining recognition from nursing management might

prevent nurses from searching for recognition in care relationships with patients or their family members.

As a consequence for nurse managers, producing a supporting work environment with individualized

considerations (Avolio, Bass, & Jung, 1999) which focus on understanding the needs of the nurses

appears to be important. Moreover, a review of Cummings et al. (2010) pointed out how a leadership

style focused on people and relationships (f.e. supportive, transformational (Bass & Avolio, 1994) and

resonant (Boyatzis & McKee, 2005; Goleman, Boyatzis, & McKee, 2002) leadership styles) is associated

with staff satisfaction with work, role and pay, staff relationships with work, staff health and wellbeing,

work environment factors, and productivity and effectiveness (Cummings et al., 2010). In contrast, a

negative association was observed between the former outcomes and leadership styles focusing on

tasks to be accomplished (f.e. dissonant (Goleman et al., 2002), instrumental (Antonakis & House, 2002)

and management by exception (Avolio et al., 1999) leadership styles). The authors conclude that by

investing energy into relationships with nurses, relational leaders positively affect the health and well-

being of their nurses, and, ultimately, the outcomes for patients (Cummings et al., 2010). Creating a

work environment which displays concern for its caregivers as persons and which builds trust through

responding to staff concerns seems to be very important. Moreover, leadership styles which focus

primarily on the task to be completed may not be tuned to the emotional needs of staff as they provide

complex care, and as such, might not understand the difficult times caregivers go through. Especially in

a context of experiencing and perceiving aggression and transgressive behaviour, nurse leaders who

are relationally focused seem to be important.

A final recommendation for nursing management pertains to an important part of the results of the

interviews with patients regarding their perceptions of transgressive behaviour. Patients expressed the

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expectation to encounter competent and skilled professionals during their hospital stay. This expectation

was presumed to be part of a basic trust in professionals because they are part of professional

institutions which regulate practices and endorse trustworthiness of professional activities (Dinç &

Gastmans, 2012). Patients perceived receiving competent care as self-evident. Despite this expectation,

several patients referred to experiences where the nurses’ professional expertise was questionable and

even inadequate. For example, patients narrated about nurses not recognizing an epileptic seizure,

about getting the wrong medication, repeatedly getting medication they were allergic to despite their

own warning, not getting their pain medication, etc. These recollections of patients can serve to be a

considerable sort of ‘wake-up’ call for management, as these examples pertain to a core process of

caregiving: the very quality of care that ‘users’ of a hospital receive. Professional competences and

expertise have a considerable impact on the quality of care, and realizing the quality policy is an

important objective of nursing management (Glouberman & Mintzberg, 2001). The findings on the

patients’ experiences of their hospital admission underline the importance of drawing on the perspective

of people ‘undergoing’ diverse and intricate processes of caregiving in hospitals. Even though patients

in this dissertation’s study talked about just a few personal –and easily articulated- experiences, similar

experiences do not become ‘visible’ if the patients’ perspective regarding the care they receive is not

considered to be a valid and valuable representation of what occurs in basic caregiving processes (Ross

et al., 2014). This recommendation fits with the general recognition of patient participation as a key

component in the redesign of healthcare processes, and as a means to improve patient safety (World

Health Organisation, 2005; Longtin et al., 2010). In literature, there are some initiatives on the

involvement of stakeholders (in particular patients and their representatives) in hosp ital’s decision

structures (Longtin et al., 2010; Ross et al., 2014; Malfait, Van Hecke, Hellings, De Bodt, & Eeckloo,

2017) pointing out how the involvement of stakeholders proves to be an important method to address

the quality of care and client-centeredness in an organization (Malfait et al., 2017).

7. | Methodological considerations

Each separate study of this dissertation has methodological limitations which have been described and

discussed in the previous chapters. What follows are more general methodological considerations that

pertain to several studies at once.

General discussion

189

A transversal representation of nurses’ and patients’ perceptions of transgressive behaviour

was gained. Both nurses and patients were interviewed only once, which makes it difficult to ascertain

whether nurses’ and patients’ perceptions of transgressive behaviour change over time based on

subsequent interactions with patients or with nurses. In subsequent interactions, it is possible that there

are experiences in the interpersonal contact that ‘counterbalance’ experiences or perceptions of

aggression or transgressive behaviour. This possibility is described further as a recommendation for

further research (please see recommendations for further research).

Patients were approached as solitary people. In exploring patients’ perspectives of transgressive

behaviour in care relationships, their individual perspective was examined. This means there is no data

on the interaction between patients and their family members or network regarding experiences or

perceptions of transgressive behaviour. As the perspective of family members regarding transgressive

behaviour in care relationships was not in the scope of this dissertation, this is not considered to be a

methodological limitation. However, insight into interactions between patients and their network

concerning transgressive behaviour in care relationships would have rendered an additional

understanding as one can presume that the patients’ perspective regarding transgressive behaviour in

care relationships is profoundly influenced by the meaning family members attribute to specific incidents.

As such, adopting the family members’ perspective is suggested as a recommendation for further

research (please see recommendations for further research).

Recollections of experiences of aggression and transgressive behaviour were gathered. Both

questionnaires and interviews were used to collect data. The questionnaire that was used collects data

on nurses’ experiences of aggression that occurred in the past year. This time frame induces the risk

that past experiences of aggression are forgotten, or one extreme aggressive incident profoundly

influences recollections of experiences of aggression. Moreover, recollections of past experiences of

aggression and transgressive behaviour –collected through both the questionnaire and the interviews-

might be subject to a form of cognitive coping. This means that experiences are already processed, and

that the emotional meaning or impact of experiences is no longer present. As such, the emotions that

were present in experiencing incidents no longer overwhelm participants in recollecting their

experiences of aggression or transgressive behaviour. Given the ways in which both patients and nurses

adopt strategies to overcome or deal with incidents of aggression and transgressive behaviour, it is

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important to acknowledge that experiences might already be reframed by the participant. This is a

limitation of the studies.

An abstraction of experiences of aggression and transgressive behaviour was required. Nurses

and patients were interviewed regarding their experiences of aggression and transgressive behaviour.

In addition to the circumstances where nurses and patients were asked to recollect past experiences,

they were invited to ‘give words’ to their experiences. This has induced additional challenges for analysis

since the usage of words imposes a restriction. Using words requires an abstract representation of

experiences and perceptions. For example, stating that an experience was ‘emotionally difficult’, ‘very

distressing’ or ‘quite painful’ is a very abstract representation of the real emotions and cognitions that

are involved in particular situations. Hence, an extensive form of investigator triangulation was important

to compensate for this abstraction and reconstruction in words. By involving different researchers,

different perspectives were obtained which helped recover implicit data hidden behind words. This

approach in analysis helped to elicit nuance in the understanding of the data (Rubin & Rubin, 1995).

Homogeneity in patients’ characteristics. The findings mainly pertain to Caucasian, Dutch-speaking

patients. Patients who were not able to speak Dutch were excluded from the study. As such, it is not

known whether non-Dutch speaking patients experience or perceive aggression or transgressive

behaviour the same way as was noted in present study’s findings on the patients’ perspective.

Furthermore, one can question whether primarily articulate and self-reflexive patients participated in the

interviews. Even though no patients refused to take part in the study, it might be possible that patients

who are articulate about their experiences in care relationships were more inclined to participate. As

such, there is a risk that present findings mainly represent the experiences of ‘articulate patients’. Even

if this were the case, the representation of ‘articulate patients’ on what occurs in care relationships with

nurses in a context of transgressive behaviour, can still be valuable for patients who cannot easily voice

what they experience in care relationships with nurses in a context of transgressive behaviour. The

concept that underpins this notion, is the authenticity of the study. Lincoln & Guba (1989) add

authenticity to the criteria for methodological adequacy, and describe how a study is (ontological)

authentic when participants and similar groups are helped to understand their world. As such, a study

is authentic when the findings help participants -or other patients in case of this dissertation- to

understand their social world, or human condition (Lincoln & Guba 1989).

General discussion

191

Involved researchers were mainly nurses. The different studies were conducted by a team of

researchers which mainly consisted of nurses. It is reasonable to believe that this professional

background entails preconceived ideas about care relationships between nurses and patients. This is

important to consider as researchers co-construct and affect data collection as well as the results, and

these considerations are particularly important in conducting grounded theory research. How

researchers should address their preconceived ideas on the phenomenon under research is a

discussion point in grounded theory, with a substantial difference between traditional or objectivist

grounded theory approaches and constructivist grounded theory approaches (Charmaz, 2008).

According to the former approach, based on the Glaserian and Straussian schools of grounded theory,

the researcher should ideally be unbiased and know very little of the phenomenon under research so

as not to disturb the analysis and understanding of the phenomenon of interest by preconceived ideas.

But according to a more constructivist grounded theory approach, the researcher is a ‘situated

knowledge producer’ (Charmaz, 2009) who does not only acknowledge preconceived ideas but uses

them in order to better understand the phenomenon of interest. In this dissertation, this meant that the

researchers’ preconceived ideas about care relationships in general were acknowledged, critically

appraised and used as gradually developing theoretical sensitivity (Charmaz, 2008). Moreover,

researcher triangulation was adopted which safeguarded controlled usage of subjectivity, and avoided

premature stranding in theoretical concepts. Critical reasoning, a general openness to the unexpected

and the constructed interpretations of the various researchers expanded the understanding of

theoretical possibilities and the emerging theoretical constructs.

8. | Recommendations for further research

A few recommendations for further research will be addressed and described based on the

methodological approaches in this dissertation, the findings and the limitations of the separate studies.

Transgressive behaviour in care relationships between patients and caregivers that are not

nurses. Aggression and transgressive behaviour in care relationships between nurses and patients

made up the starting-point of this dissertation. However, experiences of aggression and transgressive

behaviour in care relationships do not occur solely in the disciplinary group of nurses (Stubbs,

Winstanley, Alderman, & Birkett-Swan, 2009; Wu et al., 2015; Kowalczuk & Krajewska-Kulak, 2017).

Hahn et al. (2013), in studying risk factors of patient and visitor violence in different disciplinary groups,

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pointed out how out of all staff groups, only medical doctors had a significant lower rate of experiencing

patient and visitor violence. When the care relationship with patients or clients is characterized by long-

term support, patients or clients are actively involved in their treatment regime or in short, there is a

interpersonal relationship between the caregiver and the patient; chances are experiences of aggression

of transgressive behaviour will transpire in these treating or guiding care relationships. Insights gained

from this dissertation’s studies might be transferred to disciplinary groups other than nurses. As such,

the findings and insights might be adopted to support (student)caregivers in their attitude-forming in care

relationships, in further developing social or communicative skills, and in gaining an indication of what it

is like for people to ‘become’ a patient or a client in a healthcare system. Further research could explore

whether the observed dynamics in nurse-patient care relationships are specific to the nursing profession,

or additional theoretical concepts play a crucial role in the interaction between patients and other

caregivers in a context of aggressive or transgressive behaviour. For instance, the very notion of what

aggressive or transgressive behaviour is, means or entails; might be different for other disciplinary

groups. Furthermore, the dynamics that were observed in nursing teams influenced nurses’ perceptions

of transgressive behaviour. It would be interesting to explore the dynamics in teams of other disciplinary

groups regarding transgressive behaviour, and whether or not similar group processes emerge.

Processes and dynamics in care relationships that might counterbalance experiences and

perceptions of aggression and transgressive behaviour. This dissertation focused on experiences

and perceptions of aggression and transgressive behaviour in care relationships between nurses and

patients. Even though this focus was an essential starting-point of this research, this focus entails an

inherent focus on ‘negative’ aspects in care relationships between nurses and patients. A focus on what

‘goes wrong’ in care relationships does not necessarily provide insight into processes that might

counterbalance certain experiences of transgressive behaviour. A longitudinal approach in exploring

what occurs in care relationships in a context of aggression and transgressive behaviour could render

an additional understanding. Present findings, in adopting a transversal approach, provide a mere

indication on what might occur in subsequent contacts following transgressive behaviour. For instance,

the ‘labelling’ of patients as difficult patients appeared to result in subsequent strained interactions

between nurses and patients, a finding confirmed in literature (Koekkoek, Hutschemaekers, van Meijel,

& Schene, 2011; Price, 2013). However, the perceived seriousness of transgressive behaviour was

regulated and mitigated by the existence of a trusting relationship between the nurse and the patient.

General discussion

193

The extent to which the patient’s perspective was understood by the nurse, also mitigated the

seriousness of perceived transgressive behaviour. These aspects in care relationships would be

interesting to examine in further research. A longitudinal approach in this research is deemed

appropriate as it can be presumed that a trusting relationship or the ability to understand the patient’s

perspective are aspects that develop over time.

The significance of complexity theory in understanding interactions and relationships among

nursing team members. A central notion of complexity theory is the idea that groups of living people

or organisations can be described as complex adaptive systems (Holden, 2005). A complex adaptive

system is a collection of individual agents with freedom to act in ways that are not always totally

predictable, and whose actions are interconnected so that one agent's actions changes the context for

other agents (Plsek & Greenhalgh, 2001). A perspective as such in focusing on systems thinking has a

long tradition in nursing (Fawcett, 2000). Present findings on nursing team interactions (chapter VI)

suggest that nursing teams can be conceptualised as complex adaptive systems. Attributes of complex

adaptive systems emerge in the nursing team interactions. For example, the self-imposed rules among

nurses can be conceptualized as internalised rules (Wilson, Holt, & Greenhalgh 2001). Conforming to

informal group norms and gaining protection from the group can be conceptualised as attractor

behaviour of nurses (Plsek & Wilson, 2001). Professional socialising processes can be conceptualised

as an adaption of agents within the system (Plsek & Greenhalgh, 2001). Research on the meaning of

complexity theory for health care research is increasing (McDaniel, Lanham, & Anderson, 2009; Pype

et al., 2017) as complexity theory appears particularly applicable for studying relationships and

interactions between health care professionals (Thompson et al., 2016). Future research could adopt

complexity theory as the conceptual framework and design to understand nursing teams as complex

adaptive systems.

Nurses’ and patients’ perspectives of aggression and transgressive behaviour, based on the

‘same’ incidents. In exploring nurses’ and patients’ perceptions of transgressive behaviour, their own

individual perspective was adopted. This starting-point was self-evident as an objective of this

dissertation was obtaining an understanding of the meaning of aggression and transgressive behaviour

in care relationships. In order to gain insight into the meaning nurses and patients attributed to incidents,

it was important not to impose standards or norms which had to be at stake to experience aggression

or transgressive behaviour. The individual and subjectifying approach made sure the meaning of

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aggression and transgressive behaviour was reached and clarified. This approach also entailed that

nurses and patients were not elaborating on the same incidents of aggression or transgressive

behaviour, implying that both perspectives were not explored regarding one singular incident or

interaction. Using such an approach would have implied that ‘what’ is an incident would have been

imposed already by the researchers. Nevertheless, a direct comparison of both perspectives on the

same incidents of aggression and transgressive behaviour can render an additional understanding of

how both perspectives influence each other regarding concrete incidents in nursing practice. As such,

different versions of the same incident could be presented, allowing an analysis of why in these

circumstances contradictory understandings can be held by nurses and patients (Rubin & Rubin, 1995).

Initiatives to guide and prepare pregraduate-nurses for professional socialisation in nursing

practice. In exploring associations between different patient-related, nurse-related and work-related

characteristics and nurses’ perceptions of aggression, an association was observed between nurses’

primary tasks and their perceptions regarding aggression. When nurses’ primary task was the education

of nursing students, a higher likelihood of perceiving aggression as a dysfunctional phenomenon was

observed. This association was presumed to exist because of the protective role these nurses might

adopt towards students, making them more prone to perceive aggression as undesirable and disturbing.

The protective role nurses adopt towards their colleagues was also observed in the group dynamics in

nursing teams on account of experiences of transgressive behaviour. In this interaction among

colleagues, a tendency to adopt a hardened attitude towards patients’ transgressive behaviour was also

observed in reaction to an incident where a colleague experiences transgressive behaviour. These

dynamics were framed in a process of professional socialisation (Clouder, 2001; Mooney, 2007; Bisholt,

2012). A similar process might exist in the perception of nurses in practice who educate and guide

nursing students. This finding warrants further exploration to understand how pregraduate-nurses can

be guided or prepared for these socialisation processes. Different studies have pointed out that there is

a tension between the academic environment of the nursing education, and the professional

environment (Bisholt, 2012; Thrysoe, 2012). A high degree of adaption of student nurses or novice

nurses is requested in facing differences between the professional values that are learned in nursing

school, and the organisational values that are acquired in the workplace. The professional value in

nursing education is patient-oriented, while the organisational value in nursing practice is task-oriented

(Feng & Tsai, 2012). Further research could explore how pregraduate-nurses can be prepared and

General discussion

195

guided in dealing with these socialisation processes without feeling restrained in their daily practices in

working within confined limitations (Mooney, 2007).

Family member’s perspective regarding aggression and transgressive behaviour in care

relationships. As mentioned before, the patient’s perspective was approached as an individual

perspective. There is no insight into the family member’s perspective, or the interaction between the

patient and his/her family members. Further research might focus on how experiences of aggression or

transgressive behaviour of patients and their family members’ are subject to a dynamic interaction, and

mutually influence each other. Family members for instance, might be inclined to validate and support

the patient’s perspective regarding transgressive behaviour of nurses, or might be inclined to soothe the

patient’s interpretation of nurse’s transgressive behaviour. The pattern that was observed in patients’

response to transgressive behaviour of searching for own solutions and asking family members to bring

medication from home, provides a mere indication of the interaction between the patient and his/her

family members. Present findings do not provide insight into what exactly goes on in this interaction.

However, in exploring aggression and transgressive behaviour in care relationships, a complex social

situation is studied which warrants a multidimensional approach (Duxbury, 2002). As such,

understanding the family members’ perspective and influence on the patients’ perspective is important.

In this context, it is also important to refer to the results about the prevalence of aggression caused by

patients’ family members. A lot of hospital nurses and primary care nurses indicated to experience verbal

aggression, physical aggression and threats by patients’ family members. In only considering the ‘one

time’- exposure of nurses to aggression, nurses marked that almost all forms of aggression were more

frequently caused by patients’ family members than by patients themselves. These results demonstrate

it is important to understand which underlying processes explain why and how aggression or

transgressive behaviour occurs in the relationships between nurses and patients’ family members.

Extant literature on aggression in care relationships primarily focuses on nurse-patient relationships,

and only marginally considers aggression or transgressive behaviour of patients’ family members.

Moreover, when family members or relatives are involved in research on aggression in care

relationships, they are mostly conglomerated with the occurrence of patient aggression (Lepping, Lanka,

Turner, Stanaway, & Krishna, 2013; Wei, Chiou, Chien, & Huang, 2016; Najafi et al., 2017). Further

research could focus on gaining the perspective of family members on aggression and transgressive

behaviour in care relationships, and focus on what occurs in the interaction between nurses and family

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members. Especially in primary care, where family members shoulder significant responsibilities and

concern for the patient’s care, additional insight into dynamics in interactions between nurses and family

members appears to be very important.

General discussion

197

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Summary

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SUMMARY

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Summary

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SUMMARY

Aggression in health care is not a new problem. Aggression towards healthcare workers is prevalent

and well recognized internationally as a complex problem. This complexity is related to the subjective

aspects of aggression, and the multidimensional and multifactorial nature of the occurrence of

aggression in care relationships. When compared to other caregivers, nurses appear to be at especial

risk to encounter aggression due to the nature, duration and intensity of their care relationships with

patients. Research pointed out that aggression in care relationships generates several negative

consequences for nurses, for patients, for the quality of care, and for the organisation as a whole.

Despite these important insights generated through the extant research, some gaps in current

knowledge on aggression in care relationships exist. Most studies focus on specific settings, like geriatric

settings, emergency or mental health settings. Little knowledge is available about patient aggression in

more general medical and surgical care units or in primary care. Furthermore, little is known about the

perceptions or the subjective meaning of aggression from the perspective of nurses, nor from the

perspective of patients. In addition, as most studies focus on the individual perspective of nurses

regarding aggression, scarce knowledge is available on the group dynamics or –processes in nursing

team following aggressive incidents. These gaps in extant research induced a research trajectory that

–in the form of a doctoral dissertation- tried to contribute to the literature on aggression in care

relationships by providing tentative answers to these various presented challenges.

To gain knowledge on the occurrence of patient aggression in more general settings and nurses’

perceptions of aggression, the first part of this dissertation focuses on gaining a broad indication of

nurses’ experiences of aggression in the general hospital setting and in primary care in Belgium. An

assessment instrument was needed to provide information on frequencies and characteristics of patient

aggression, and nurses’ perceptions of aggression working in these settings. As such, chapter II

addresses the translation and psychometric validation of tree assessment instruments. These three

instruments are the Survey of Violence Experienced by Staff (SOVES), the shortened Perception of

Aggression Scale (POAS-s) and the Perception of Importance of Intervention Skills Scale (POIS). This

psychometric evaluation addressed the content- and construct validity, stability, and internal

consistency, and concluded that the Dutch version of these instruments demonstrated acceptable to

good psychometric properties. Consequently, chapter III outlines the results of a cross-sectional study

adopting the three assessment instruments. This cross-sectional study including 769 nurses focuses on

210

nurses’ experiences of patient aggression and aggression by patients’ family members in primary care

and in general hospital settings. About 89.2% of hospital nurses and 77.9% of primary care nurses had

experienced aggression, and verbal aggression appeared to be most prevalent in both groups.

Aggression by patients’ family members turned out to be common among primary care nurses.

Especially primary care nurses were more emotionally burdened because of verbal aggression, physical

aggression and threats. Most nurses across both groups appealed to colleagues when aggressive

incidents occurred in order to gain support. The majority in hospital nurses and primary care nurses

indicated to report none to a few of the aggressive incidents they encountered. In addition, nurses’

perceptions of aggression were addressed. Most nurses across both groups agreed that aggression is

a dysfunctional and undesirable phenomenon. A subsequent regression-analysis revealed which factors

on the level of nurses, patients or the organization were associated with different perceptions of

aggression.

The second part of this dissertation focuses on gaining an understanding of the meaning of aggression

by adopting a more subjectifying approach of the concept of aggression. A subjectifying approach

focuses on a form of inductive reasoning to understand aggression in healthcare, and consequently,

how perceptions of aggression can emerge. In order to reach understanding of the meaning of

aggression, the term ‘transgressive behaviour’ was adopted. The use of this term allows returning to the

‘essence’ of experiencing aggression, namely a crossing of own limits, standards or norms. This

encompasses a subjective interpretation of when and what limits are exceeded for situations to be

experienced as transgressive. This means that both nurses’ and patients’ own experiences of

transgressive behaviour provided the starting-point to gain an understanding of the meaning of

aggression and the explanatory underlying processes of how these perceptions emerge. In chapter IV,

the meaning of nurses’ transgressive behaviour from the patients’ perspective is addressed. Twenty

interviews were conducted with patients that were admitted to general hospital wards. Patients appeared

to adopt a framework of suppositions which generates implicit ideas or assumptions about hospital care

and nurse-patient relationships. Hence, patients envisage how competent professional caregivers will

be and on how relationships with nurses will be characterized as normal human interactions. These

assumptions are implicit, and awareness of these assumptions occurs when patients experience

envisaged care or nurse-patient relationships are not met in their perceived reality. Experiencing these

discrepancies gives rise to a process of adaption, and several patterns are put into action: patients

Summary

211

become more vigilant with regard to care given by nurses; they search for own solutions; they make

excuses for nurses or they reprioritize their expectations. As such, patients go through both a cognitive

and emotional process in adjusting their assumptions or behaviour. Due to these processes,

experiences of transgressive behaviour are put into perspective. The transgressive aspect of

experiencing transgressive behaviour is ‘addressed’ by patients themselves by adopting different

patterns of adjustment. Subsequently, chapter V explores the onset and meaning of transgressive

behaviour from the nurses’ perspective. Eighteen nurses, working on general hospital wards were

interviewed regarding their perceptions of patients’ transgressive behaviour. These findings revealed

that nurses’ experiences of transgressive behaviour were associated with a complex interplay of both

determining and regulating factors. These factors affect which incidents are perceived as transgressive

and what meaning is assigned to them. The degree of control that nurses experience over the provision

of care, the degree of patient acceptance of organizational and ward rules, the degree of gratitude and

recognition expressed by the patient and the extent of patient regard for the nurse as a person were

identified as determining factors. As regulating factors, the extent of a trusting relationship between

patients and nurses, the extent to which the patient’s perspective is understood, the way transgressive

behaviour is managed by nurses and the roles of the nursing team and head nurse and ward culture

and habits, were identified. These different factors appeared to be connected to one another and were

responsible for particular dynamics in maintaining, reinforcing, or decreasing experiences of

transgressive behaviour. To frame these findings in a broader perspective, the group dynamics in

nursing teams on account of transgressive behaviour were examined. Twenty-four nurses, working in

general hospital settings, were interviewed. Chapter VI outlines these results. Different patterns of

interactions were observed in nursing teams following experiences of transgressive behaviour: nurses

talked to and excused one another; filled in for one another; informed and warned one another; and

defended, protected and safeguarded one another. These patterns in reaction to patients’ transgressive

behaviour seem to be underpinned by the motivation to protect the group. In these interactions, implicit

group norms transpire, causing nursing teams to acquire their specific identity “as a group”. These

informal group norms in nursing teams appeared to impinge how nurses feel threatened by patients’

potential transgressive behaviour; gain protection from the group of nurses and conform to informal ward

rules.

212

The findings of this dissertation contribute to the extant knowledge on what occurs in nurse-patient care

relationships in a context of aggression and transgressive behaviour. Even though aggression as a

phenomenon in care relationships has been the subject of abundant research, a ‘novel’ approach was

adopted for this dissertation. The onset and meaning of ‘transgressive behaviour’ in care relationships

was explored. This was done by quantitatively examining nurses’ experiences and perceptions of

aggression, and by qualitatively studying what transgressive behaviour is for patients, means for nurses,

and causes in nursing teams. The findings underline the complexity and multidimensional nature of

aggression and transgressive behaviour in care relationships. In addition, behaviour in itself does not

determine ‘what’ is experienced as aggressive or transgressive behaviour. Underlying dynamic

processes in patients’ and nurses’ perceptions were identified that determine the meaning that is

attributed to specific interactions in care relationships. The findings of this dissertation offer patients,

student-nurses, nurses and nursing managers a comprehensible framework of what occurs in nurse-

patient care relationships when aggression or transgressive behaviour is experienced or perceived. The

findings can provide content (or form the basis) of a policy to clarify, understand and remedy aggression

and transgressive behaviour in practice.

Samenvatting

213

SAMENVATTING

214

Samenvatting

215

SAMENVATTING

Agressie vormt geen nieuw probleem in de zorgverlening. Nationale en internationale literatuur erkent

agressie als een complex probleem in ziekenhuizen wereldwijd. Deze complexiteit heeft te maken met

de subjectieve aspecten van agressie, en het multidimensionale en multifactoriële karakter van het

voorvallen van agressie in zorgrelaties. Van alle zorgverleners blijken verpleegkundigen in het bijzonder

een risico te lopen op het ervaren van agressie omwille van de aard, de duur en de intensiteit van hun

zorgrelaties met patiënten. Bestaand onderzoek heeft verder ook aangetoond dat het voorkomen van

agressie in zorgrelaties een aantal negatieve gevolgen genereert voor verpleegkundigen, voor

patiënten, en voor de kwaliteit van de zorgverlening. Ook op het niveau van de organisatie worden een

aantal belangrijke overkoepelende negatieve gevolgen geïdentificeerd van agressie in

zorgverleningsrelaties. Niettegenstaande deze belangrijke inzichten uit bestaand onderzoek, zijn er een

aantal hiaten aanwezig in de bestaande kennis over agressie in zorgrelaties. De meeste literatuur over

agressie richt zich bijvoorbeeld vooral op een aantal specifieke settings, zoals geriatrische settings, en

spoed- en psychiatrische afdelingen. Over het voorkomen van agressie in meer generieke settings,

zoals algemene ziekenhuisafdelingen of de eerstelijnszorg, is niet veel geweten. Er is verder ook weinig

literatuur voorhanden over de percepties en de subjectieve betekenis van agressie vanuit het

perspectief van verpleegkundigen, of vanuit het perspectief van patiënten. Doordat bestaande literatuur

zich bovendien vooral richt op het individuele perspectief van verpleegkundigen ten aanzien van

agressie, is er ook nog erg weinig kennis beschikbaar over de groepsdynamieken en -processen in

verpleegkundige teams naar aanleiding van agressie-incidenten. Deze hiaten in bestaand onderzoek

over agressie in zorgrelaties vormden de aanleiding voor een onderzoekstraject dat -onder de vorm van

een doctoraatsonderzoek- op verschillende domeinen antwoorden probeerde te formuleren.

Om meer te weten over het voorvallen van agressie in meer generieke settings, en de percepties van

verpleegkundigen over agressie, richt het eerste deel van dit onderzoekstraject zich op het verkrijgen

van een brede indicatie van agressie-ervaringen van verpleegkundigen op algemene

ziekenhuisafdelingen en in de eerstelijnszorg. Het verkrijgen van een gevalideerd assessment

instrument was vervolgens belangrijk om informatie in te winnen over de frequenties en karakteristieken

van agressie, en de percepties over agressie van deze verpleegkundigen. Hoofdstuk II richt zich

daarom op de vertaling en psychometrische validering van drie assessment instrumenten. Deze drie

instrumenten zijn de Survey of Violence Experienced by Staff (SOVES), the shortened Perception of

216

Aggression Scale (POAS-s) en the Perception of Importance of Intervention Skills Scale (POIS). Bij

deze psychometrische evaluatie werd de inhoudsvaliditeit, construct validiteit, stabiliteit en interne

consistentie nagegaan, waaruit bleek dat de Nederlandstalige versies van deze instrumenten

acceptabele tot goede psychometrische kenmerken hadden. In hoofdstuk III worden vervolgens de

resultaten toegelicht van een cross-sectionele studie waarbij de drie assessment instrumenten gebruikt

werden. Deze cross-sectionele studie bij 769 verpleegkundigen (werkzaam op algemene

ziekenhuisafdelingen en in de thuiszorg) richtte zich op hun ervaringen met agressie van patiënten en

van de familieleden van patiënten. Uit deze resultaten blijkt dat 89.2% van de

ziekenhuisverpleegkundigen, en 77.9% van de thuisverpleegkundigen al agressie ervaren had, en

verbale agressie bleek bij beide groepen verpleegkundigen het vaakst voor te komen. Agressie door de

familieleden van patiënten bleek frequent voor te komen bij thuisverpleegkundigen. Vooral

thuisverpleegkundigen ervoeren ook een belangrijke emotionele impact van het ervaren van verbale

agressie, fysieke agressie of bedreigingen. De meeste verpleegkundigen in beide groepen deden

overwegend beroep op collega’s wanneer agressie-incidenten zich voordeden om ondersteund te

worden. De meeste ziekenhuisverpleegkundigen en thuisverpleegkundigen gaven daarbij ook aan dat

agressie-incidenten niet tot slechts heel beperkt gerapporteerd werden. Daarnaast werd ook bekeken

op welke manier verpleegkundigen agressie percipieerden. De meeste verpleegkundigen uit beide

groepen waren het eens met het idee dat agressie een erg dysfunctioneel en ongewenst fenomeen is.

Bovendien werd via een regressie-analyse ook gekeken naar welke factoren geassocieerd zijn met

verschillende percepties over agressie.

Het tweede deel van het onderzoekstraject richt zich vooral op het verkrijgen van inzicht in de

subjectieve betekenis van agressie. Het zoeken naar deze subjectieve betekenis ging uit van een vorm

van inductief redeneren om agressie in zorgrelaties te begrijpen, en om te begrijpen hoe percepties over

agressie zich vormen. Om inzicht te krijgen in de subjectieve betekenis van agressie werd gebruik

gemaakt van de term ‘grensoverschrijdend gedrag’. Het hanteren van deze term laat toe om terug te

keren naar de essentie van het ervaren van agressie, namelijk het overschrijden van bepaalde grenzen,

normen of waarden. Dit veronderstelt verder een subjectieve interpretatie over wanneer en welke

grenzen overschreden worden om bepaalde interacties of situaties als grensoverschrijdend te ervaren.

Bij het hanteren van de term ‘grensoverschrijdend gedrag’ werd vooral uitgegaan van de eigen

ervaringen en percepties van verpleegkundigen en patiënten over wat zij in het contact met elkaar

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grensoverschrijdend vonden. Door kwalitatieve theorievormende onderzoeken werd gezocht naar de

ontstaansmechanismen en de onderliggende processen in het percipiëren van grensoverschrijdend

gedrag in zorgrelaties. In hoofdstuk IV wordt het perspectief van patiënten over grensoverschrijdend

gedrag door verpleegkundigen toegelicht. Daarbij werden 20 interviews afgenomen met patiënten die

opgenomen waren op algemene ziekenhuisafdelingen. Patiënten blijken een impliciet referentiekader

te hanteren waarbinnen ze de zorg in het ziekenhuis en de zorgrelaties met verpleegkundigen plaatsen.

Dit kader creëert de verwachting dat ze zich in het ziekenhuis in deskundige en capabele handen zullen

bevinden, en de zorgrelaties met verpleegkundigen zich zullen voordoen als normale, menselijke

interacties. Wanneer patiënten gewaar worden dat deze verwachtingen op beide domeinen niet

vanzelfsprekend en logisch zijn, ervaren ze een discrepantie tussen hun verwachtingen en de ervaren

zorgrealiteit. Het ervaren van deze discrepantie zorgt ervoor dat patiënten zich gaan aanpassen, en vier

patronen konden geïdentificeerd worden: patiënten werden meer waakzaam, kritisch en controlerend

over de zorg; patiënten zochten naar eigen oplossingen; patiënten waren geneigd verpleegkundigen te

verontschuldigen; of patiënten passen verregaand hun verwachtingen aan. Op deze manier gaan

patiënten door zowel een cognitief als emotioneel proces in het aanpassen van hun verwachtingen of

hun gedrag. Door deze verschillende processen, worden hun ervaringen van grensoverschrijdend

gedrag gerelativeerd. Het ‘grensoverschrijdende’ aspect wordt aangepakt door patiënten zelf door het

hanteren van verschillende aanpassingsprocessen.

In hoofdstuk V wordt vervolgens het perspectief van verpleegkundigen toegelicht. Achttien

verpleegkundigen, werkzaam op algemene ziekenhuisafdelingen, werden over hun percepties van

grensoverschrijdend gedrag door patiënten bevraagd. De beleving en betekenisgeving van

verpleegkundigen blijkt samen te hangen met een complex samenspel van bepalende en regulerende

factoren in het percipiëren van grensoverschrijdend gedrag. Deze factoren bepalen welke situaties als

grensoverschrijdend ervaren worden, en welke betekenis deze vervolgens toebedeeld worden. De mate

van ervaren controle op de zorgorganisatie, de mate van conformerend gedrag van de patiënt en diens

familie, de mate van diskwalificatie van de eigen persoon, en de mate van gekregen dankbaarheid en

erkenning werden als bepalende factoren geïdentificeerd. Als regulerende factoren werd de mate

waarin een vertrouwensrelatie bestond tussen de patiënt en de verpleegkundige, de mate waarin het

perspectief van de patiënt gezien werd, de manier waarop met grensoverschrijdend gedrag omgegaan

werd, en de beïnvloeding van het verpleegkundig team, en de invloed van de afdelingscultuur- en

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gewoontes geïdentificeerd. Deze factoren bleken met elkaar verbonden te zijn, en zijn verantwoordelijk

voor een eigen dynamiek in het onderhouden, versterken of verminderen van ervaringen van

grensoverschrijdend gedrag. Om deze bevindingen in een breder perspectief te plaatsen, werden ook

de groepsdynamieken in verpleegkundige teams naar aanleiding van grensoverschrijdend gedrag

verder onderzocht. Om zicht te krijgen op deze groepsdynamieken werden 24 verpleegkundigen

bevraagd. In hoofdstuk VI worden deze resultaten toegelicht. Verschillende patronen werden

geobserveerd in de interacties tussen verpleegkundigen onderling na ervaringen van

grensoverschrijdend gedrag: verpleegkundigen spraken elkaar aan en verontschuldigden elkaar;

namen zorgtaken bij elkaar over; informeerden en waarschuwden elkaar; en beschermen, verdedigden

en vrijwaarden elkaar. Deze patronen naar aanleiding van grensoverschrijdend gedag van patiënten of

familieleden lijken voort te vloeien vanuit een motivatie om de groep verpleegkundigen te beschermen.

In deze interactie blijken impliciete groepsnormen op te treden waardoor verpleegkundige teams hun

specifieke betekenis en identiteit ‘als groep’ ontwikkelen. Deze informele groepsnormen in

verpleegkundige teams bleken een invloed uit te oefenen op de manier waarop verpleegkundigen zich

bedreigd voelden door potentieel grensoverschrijdend gedrag van patiënten, vervolgens bescherming

genoten in de groep verpleegkundigen en zich hierdoor ook conformeerden aan informele

afdelingsregels.

De bevindingen uit dit doctoraatsonderzoek vormen een aanvulling op de bestaande kennis over wat

zich afspeelt in zorgrelaties tussen verpleegkundigen en patiënten in een context van agressie en

grensoverschrijdend gedrag. Alhoewel agressie als fenomeen in zorgrelaties al vaak onderzocht is,

werd voor het doctoraatsonderzoek een ‘vernieuwende’ benadering gehanteerd. De betekenis van

‘grensoverschrijdend gedrag’ in zorgrelaties werd geëxploreerd. Dit gebeurde door het kwantitatief

bekijken van de ervaringen en percepties van verpleegkundigen over agressie, en het kwalitatief

onderzoeken van wat grensoverschrijdend gedrag is voor patiënten, betekent voor verpleegkundigen

en vervolgens teweegbrengt in verpleegkundige teams. De bevindingen onderschrijven de complexiteit

en het multidimensionale karakter van agressie en grensoverschrijdend gedrag in zorgrelaties. Daarbij

komt dat gedrag op zich niet bepaalt ‘wat’ als agressief of als grensoverschrijdend gedrag ervaren wordt.

Onderliggende dynamische processen bij zowel patiënten als verpleegkundigen werden geïdentificeerd

die bepalen welke betekenis toebedeeld wordt aan bepaalde interacties in zorgrelaties. De bevindingen

van dit proefschrift bieden patiënten, student-verpleegkundigen, verpleegkundigen en verpleegkundig

Samenvatting

219

managers een inzichtelijk referentiekader over wat zich afspeelt in zorgrelaties tussen verpleegkundigen

en patiënten wanneer agressie of grensoverschrijdend ervaren of gepercipieerd wordt. Ze kunnen mee

inhoud geven (of de basis vormen) aan een beleid dat agressie en grensoverschrijdend gedrag in de

praktijk begrijpelijk maakt, en remedieert.

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CURRICULUM VITAE

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Curriculum Vitae

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CURRICULUM VITAE

PERSONAL DATA

Date and place of birth December 2nd 1987, Torhout (Belgium)

Married to Filiep Taverniers

Address Kleine Heirenthoek 18, 9880 Landegem, Nevele

Contact [email protected]

EDUCATION

2005-2008 Bachelor of Nursing – University College Brugge-Oostende

2008-2011 Master of Science in Nursing and Midwifery – Ghent University

Thesis: Caregiving for older people with cancer: a qualitative study on the

experiences of family members

WORK EXPERIENCE

10.2010-12.2010 Scientific staff – University Centre for Nursing & Midwifery, Department of Public Health,

Ghent University

10.2009-06.2012 Scientific staff – Research in oncology and geriatrics, federal government project,

Geriatrics department, University Hospital Ghent

07.2008-current Primary care nurse, independent practice

03.2011-current PhD student - University Centre for Nursing & Midwifery, Department of Public Health,

Ghent University

12.2011-current Researcher – University college VIVES, Department of Health, Roeselare

ADDITIONAL TRAINING

2011 Basic assistant training, Ghent University

2014 Medical & Scientific writing, Doctoral Schools, Ghent University

2014, 2015 & 2016 Summer School for Doctoral Studies - European Academy of Nursing Science

2016 Kwalitatief onderzoek in de gezondheidszorg: basiskaders voor de meest gebruikte

kwalitatieve onderzoeksmethoden, Doctoral Schools, Ghent University

2017 Workshop Discourse analysis, European Congress of Qualitative Inquiry

2017 Workshop Qualitative evidence synthesis, European Congress of Qualitative Inquiry

2017 Kwalitatief onderzoek in de gezondheidszorg: specifieke designs en -methoden voor

gevorderden, Doctoral Schools, Ghent University

2017 Argumentation and debating techniques – Summer School Let’s talk Science, Doctoral

Schools, Ghent University

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PUBLICATIONS

Publications in international journals included in the science citation index

Vandecasteele, T., Van Hecke, A., Duprez, V., Beeckman, D., Debyser, B., Grypdonck, M., & Verhaeghe, S.

(2017). The influence of team members on nurses’ perceptions of transgressive behaviour in care relationships: A

qualitative study. Journal of Advanced Nursing, 00, 1-12.

Vandewalle, J., Debyser, B., Beeckman, D., Vandecasteele, T., Deproost, E., Van Hecke, A., & Verhaeghe, S.

(2017). Constructing a positive identity: A qualitative study of the driving forces of peer workers in mental health-

care systems, International Journal of Mental Health Nursing.

Duprez, V., Vandecasteele, T., Beeckman, D., Verhaeghe, S., & Van Hecke, A. (2016). The effectiveness of

interventions to enhance self-management support competencies in the nursing profession: a systematic review.


Vandewalle, J., Debyser, B., Beeckman, D., Vandecasteele, T., Van Hecke, A., & Verhaeghe, S. (2016) Peer

workers' perceptions and experiences of barriers to implementation of peer worker roles in mental health services:

A literature review. International Journal of Nursing Studies, 60, 234-250.

Vandecasteele, T., Debyser, B., Van Hecke, A., De Backer, T., Beeckman, D., & Verhaeghe, S. (2015). Patients’

perceptions of transgressive behaviour in care relationships with nurses: a qualitative study. Journal of Advanced

Nursing, 71(12), 2822–2833.


perceptions of transgressive behaviour in care relationships: a qualitative study. Journal of Advanced Nursing,

71(12), 2786–2798.

Vandecasteele, T., Senden, C. (joint first authorship), Vandenberghe, E., Versluys, K., Piers, R., Grypdonck, M.,

& Van Den Noortgate, N. (2014). The interaction between lived experiences of older patients and their family

caregivers confronted with a cancer diagnosis and treatment: A qualitative study. International Journal of Nursing

Studies, 52(1), 197-206.

Publications in national journals

Debyser, B., De Backer, T., Vandecasteele, T., Demuynck, E., & Verhaeghe, S. (2013). Grensoverschrijdend

gedrag in de zorgrelatie: het perspectief van algemeen ziekenhuisverpleegkundigen. Verpleegkunde, 3, 4 – 11.

Chapters in books

Senden, C., Vandecasteele, T., Vandenberghe, E., Versluys, K., Grypdonck, M., Deveugele, M. & Van Den

Noortgate, N. Ziekte- en zorgbeleving bij ouderen met kanker. In Senden, C., Versluys, K., Piers, R., Grypdonck,

M., Van Den Noortgate, N. (2014) Zorgen voor zieke ouderen tot het einde. Levensverhalen tonen de weg. Tielt:

Uitgeverij Lannoo

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PRESENTATIONS

Presentations at international conferences

Vandecasteele, T., Van Hecke, A., Debyser, B., Vanderplancke, T., Beeckman, D., & Verhaeghe, S. (2017). The

Dutch version of the SOVES, the POAS-s and the POIS to measure patient aggression in general hospitals: A

validation study. Oral presentation at CARE4 - International Scientific Nursing and Midwifery Congress. Antwerp,

Belgium.

Verhaeghe, S., & Vandecasteele, T. (2017). Thinking aloud in qualitative interviews: thinking and reasoning

processes in praxis. Oral presentation at the European congress of Qualitative Inquiry. Leuven, Belgium.

Bastiaens, H., Verhaeghe, S., Van Hecke, A., Anthierens, S., & Vandecasteele, T. (2016). Workshop: Match your

research question with the appropriate qualitative approach. Workshop at Interuniversity symposium on Qualitative

Research in Medical and Health Sciences. Leuven, Belgium.

Verhaeghe, S., & Vandecasteele T. (2016). Applying qualitative research in various health care domains. Oral

presentation at Interuniversity symposium on Qualitative Research in Medical and Health Sciences. Leuven,

Belgium.

Vandecasteele, T., Grypdonck, M., Debyser, B., Beeckman, D., Van Hecke, A., & Verhaeghe, S. (2016). Influence

of team members on nurses’ perceptions of transgressive behaviour in care relationships: A qualitative study. Oral

presentation at The 5th International Conference on Violence in the Health Sector, Dublin, Ireland.


perceptions of transgressive behaviour in care relationships: A qualitative study. Oral presentation at The 5th

International Conference on Violence in the Health Sector, Dublin, Ireland.

Vandecasteele, T., Debyser, B., Van Hecke, A., De Backer, T., Beeckman, D., & Verhaeghe, S. (2016). Patients’

perceptions of transgressive behaviour in care relationships with nurses: a qualitative study. Oral presentation at

The 5th International Conference on Violence in the Health Sector, Dublin, Ireland.

Vandecasteele, T., Debyser, B., Van Hecke, A. De Backer, T., Beeckman, D., & Verhaeghe, S. (2016). Patients’

perceptions of transgressive behaviour in care relationships with nurses: a qualitative study. Poster Presentation at

Summer School 2016, European Academy of Nursing Science, Halle (Saale), Germany.

Masquelier, E., Vandecasteele, T., & Verhaeghe, S. (2015). Family presence during resuscitation: perspective of

family members and emergency care providers. Oral presentation at Congress of the European Resuscitation

Council (Resuscitation 2015): ERC symposium on guidelines. Prague, Czech Republic.

Vandecasteele, T., Debyser, B., De Backer, T., Van Hecke, A., Beeckman, D., & Verhaeghe, S. (2014).

Transgressive behavior in health care: insight into the onset, meaning and implications for nursing practice. Oral

presentation at Summer School 2015, European Academy of Nursing Science, Barcelona, Spain.

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Transgressive Behaviour in Care Relationships: Perspectives of Nurses Working in a General Hospital. Oral

presentation at CARE4 – International Scientific Nursing and Midwifery Congress, Antwerp, Belgium.


Transgressive behavior in health care: insight into the onset, meaning and implications for nursing practice. Oral

presentation at Summer School 2014, European Academy of Nursing Science, Rennes, France.

Vandecasteele, T. , Van Hecke, A., Grypdonck, M., van Zuuren, F., Beeckman, D., & Verhaeghe, S. (2012). Lived

experiences and underlying processes of patients with refractory epilepsy and their family when referred to a

Refractory Epilepsy center: a grounded theory study. Oral presentation at 13th European Doctoral Conference in

Nursing Science, Graz, Austria.

Senden, C. , Vandecasteele, T., Vandenberghe, E., Versluys, K., Piers, R., Decoene, E., Grypdonck, M.,

Deveugele, M. & Van Den Noortgate, N. (2012). The experiences and the need for support of older cancer patients

(70+) and their family caregivers: Recommendations for nursing practice, Oral presentation at European Oncology

Nursing Society, Genève, Switzerland.

Vandecasteele, T., Versluys, K., Vandenberghe, E., Piers, R., Decoene, E., Deveugele, M., Grypdonck, M., & Van

Den Noortgate, N. (2011). The lived experience of family members of older cancer patients during a treatment with

chemotherapy and/or radiotherapy, Oral presentation at 15th International Nursing Research Conference, Madrid,

Spain.

Vandenberghe, E., Versluys, K., Vandecasteele, T., Piers, R., Decoene, E., Deveugele, M., Grypdonck, M., & Van

Den Noortgate, N. (2011). The lived experience of older cancer patients during a treatment with chemotherapy

and/or radiotherapy. Oral presentation at 15th International Nursing Research Conference, Madrid, Spain.

Vandecasteele, T., Vandenberghe, E., Senden, C., Versluys, K., Grypdonck, M., Deveugele, M., & Van Den

Noortgate, N. (2011). Experiences of older cancer patients and informal caregivers during treatment with

chemotherapie and/or radiotherapy, Poster presentation at the European Union Geriatric Medicine Society, Malaga,

Spain.

Presentations at Belgian conferences

Vandecasteele, T., Van Hecke, A., Debyser, B., Loncke, P., Verschoren, H., Patoor, I., Verkest, A., Beeckman, D.,

& Verhaeghe, S. (2016). Studienamiddag ‘Zorg zonder grenzen’: Agressie en grensoverschrijdend gedrag in

zorgrelaties. Is het een zorg in de zorg? In samenwerking met VIVES Hogeschool Roeselare. Roeselare, België.

Vandecasteele, T., Debyser, B., Van Hecke, A., De Backer, T., Beeckman, D. & Verhaeghe, S. (2016).

Grensoverschrijdend gedrag in zorgrelaties: Wat betekent het voor patiënten? Orale presentatie tijdens

avondsymposium ‘Zorg zonder grenzen: Agressie en grensoverschrijdend gedrag in zorgrelaties: Wat betekent het

voor de zorgorganisatie? Gent, België.

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227

Vandecasteele, T., Debyser, B., Van Hecke, A., De Backer, T., Beeckman, D. & Verhaeghe, S. (2016).

Grensoverschrijdend gedrag in zorgrelaties: Wat is het voor verpleegkundigen? Orale presentatie tijdens

avondsymposium ‘Zorg zonder grenzen: Agressie en grensoverschrijdend gedrag in zorgrelaties: Wa t betekent het

voor de zorgorganisatie? Gent, België.

Vandecasteele, T., Grypdonck, M., Debyser, B., Beeckman, D., Van Hecke, A., & Verhaeghe, S. (2016).

Grensoverschrijdend gedrag in zorgrelaties: Wat brengt het teweeg in verpleegkundige teams? Orale presentatie

tijdens avondsymposium ‘Zorg zonder grenzen: Agressie en grensoverschrijdend gedrag in zorgrelaties: Wat

betekent het voor de zorgorganisatie? Gent, België.


Grensoverschrijdend gedrag (GOG) in de gezondheidszorg: Inzicht in de beleving, ontstaansmechanismen en

implicaties voor de verpleegkundige praktijk. Poster presentatie op 5de editie van het Studenten

Onderzoekssymposium – Studentenraad Geneeskunde en Gezondheidswetenschappen. Gent, België.

Vandecasteele, T., Debyser, B., De Backer, T., Van Hecke, A., Beeckman, D., Verhaeghe, S. (2015).

Grensoverschrijdend gedrag (GOG) in de zorgrelatie: het perspectief van verpleegkundigen werkzaam op

algemene ziekenhuisafdelingen. Poster presentatie op 5de editie van het Studenten Onderzoekssymposium –

Studentenraad Geneeskunde en Gezondheidswetenschappen. Gent, België.

Debyser, B., De Backer, T., Vandecasteele, T., Demuynck, E., Verhaeghe, S. (2013). Grensoverschrijdend gedrag

in de gezondheidszorg: Inzicht in de ontstaansmechanismen en de betekenis. Presentatie op 39ste week van de

Verpleegkundigen en Vroedkundigen, Nieuwpoort, België.

Vandecasteele, T., & Senden, C. (2013). Beleving en ondersteuningsnoden van oudere kankerpatiënten en hun

familie: aanbevelingen voor de verpleegkundige praktijk. Presentatie op het symposium ‘Afgestemde zorg voor de

ouderen patiënt – waar onderzoek en zorg elkaar ontmoeten’. Gent, België.


Den Noortgate, N. (2011). Beleving van oudere mensen met kanker die behandeld worden met chemotherapie

en/of radiotherapie, Orale presentatie op Congres in de psychosociale oncologie, Cédric Hèle Instituut, Mechelen,

België.

Vandecasteele, T., Versluys, K., Vandenberghe, E., Piers, R., Decoene, E., Deveugele, M., Grypdonck, M., & Van

Den Noortgate, N. (2011). Beleving van familieleden van oudere mensen met kanker die behandeld worden met

chemotherapie en/of radiotherapie, Orale presentatie op Congres in de psychosociale oncologie, Cédric Hèle

Instituut, Mechelen, België.

Vandecasteele, T., Versluys, K., Vandenberghe, E., Piers, R., Decoene, E., Deveugele, M., Grypdonck, M., Van

Den Noortgate, N. - Beleving van familieleden van oudere mensen met kanker die behandeld worden met

chemotherapie en/of radiotherapie, Orale presentatie op 30ste oncologiedagen voor verpleegkundigen, Ede, 36-28

oktober 2011.


Den Noortgate, N. (2011). Beleving van oudere mensen met kanker die behandeld worden met chemotherapie

en/of radiotherapie, Orale presentatie op 30ste oncologiedagen voor verpleegkundigen, Ede, Nederland.

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REVIEWER

Journal of Advanced Nursing

SCIENTIFIC MEMBERSHIP

Student member of the European Academy of Nursing Science

Dankwoord

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DANKWOORD

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Dankwoord

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DANKWOORD

Aan het einde van een doctoraatstraject is het goed om de tijd te nemen om terug te kijken naar alle

kleine successen en grotere mislukkingen in het ganse traject van het doctoreren, en te beseffen dat

het eigenlijk wel heel mooi geweest is. Doctoreren zie ik als een avontuur. Als een gedegen leerproces,

met successen die gevierd worden, en fouten die subtiel vergeten worden. Het is een kans om met

inhoudelijke vragen op een wetenschappelijke wijze bezig te zijn. Het is dan ook een enorme luxe om

op een grondige manier een onderzoeksthema te mogen verkennen, en dat je wat eigen te maken. Ik

had daarbij ook het grote geluk dat ik me mocht omringd weten door een heleboel mensen die stuk voor

stuk op één of andere manier bewust of onbewust geholpen hebben om alles tot een goed eind te

brengen. Het past hier dan ook om deze mensen uitdrukkelijk te bedanken.

Eerst en vooral ben ik zeer dankbaar voor mijn promotor, Professor Dr. Sofie Verhaeghe. Sofie, dit

proefschrift was er zonder jou niet geweest. Je hebt me wegwijs gemaakt in de wondere wereld van

kwalitatief onderzoek, in visie-ontwikkeling, in het doceren, en het begeleiden van studenten. Ik mocht

geweldig veel van jou leren. Je vermogen om soms tegen de stroom in een heldere visie weer te geven

die onderbouwd, doordacht en compleet terecht is, is indrukwekkend. Bedankt voor de vele leuke (al

dan niet wetenschappelijke) gesprekken, onze gezellige speurtochten naar wat er in de data vervat zit,

je nuchtere kijk op de dingen, je Socratische begeleiding, je gedrevenheid, je kritische verbeteringen

van ideeën en teksten, je goede raad en je geduld, ... . Bedankt, ik mag me gelukkig prijzen met een

promotor zoals jij. Jouw vertrouwen heeft heel veel voor mij betekend.

Mijn co-promotor, Professor Dr. Ann Van Hecke, wil ik ook oprecht bedanken. Ann, je gedegen,

zorgvuldige, optimistische, en kritische blik hebben me vaak en veel verder geholpen, zowel wat betreft

de analyses, als wat betreft de publicaties. Je hebt een indrukwekkend vermogen om met het nodige

inzicht en flair een (letterlijk) einde te maken aan mijn neiging om veel te lange zinnen te maken, met

onnodig veel komma’s’, die dan nog niet eens een samenhang hebben, en dan nog daarnaast extra

ideeën bevatten die afleiden van de kerngedachte die eigenlijk al lang moest duidelijk zijn in het eerste

deel van de zin, maar die dan gewoon ook nog ondergesneeuwd wordt door die extra ideeën die er op

het einde van het verhaal niet eens zoveel meer toe doen. Bedankt om komaf te maken met die neiging

van mij ;-).

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Mijn dank gaat ook uit naar Professor Dr. Dimitri Beeckman. Bedankt om ook een rol op te nemen in de

begeleidingscommissie van dit doctoraat. Bedankt voor jouw no-nonsense aanpak, je nauwkeurig

naleeswerk, en je steuntjes in de rug. Jullie drieën samen leiden het UCVV. Het is opmerkelijk hoe jullie

voor een groot aantal erg diverse medewerkers individuele condities creëren waarbinnen medewerkers

het best kunnen werken, en tot hun recht komen. Jullie verbinden wetenschappelijke normen en

vereisten met menselijkheid over hoe het is om je doorheen een moeilijk doctoraatstraject te begeven.

Bedankt om mij de kans te geven dit doctoraatsonderzoek tot een goed eind te brengen. Ik kijk terug op

een zeer leerzaam proces en dank jullie voor jullie rol daarin.

Een speciaal woord van dank aan Professor Mieke Grypdonck. Beste Mieke, met u is voor mij alles

gestart. Ik herinner me nog goed het gesprek met u tijdens mijn masteropleiding, en de overwegingen

over welke weg nu de ‘juiste’ zou zijn. U gaf me moed en vertrouwen om de sprong naar een doctoraat

te wagen. U leerde me ook hoe belangrijk het is om authentiek te zijn, en hoe nieuwsgierigheid als

onderzoeker erg belangrijk is. U leerde me ook hoe je een puzzel niet altijd bij de randjes hoeft te

beginnen. Bedankt voor uw inspirerende steun!

Ook de leden van de jury wil ik graag bedanken: Professor Kurt Audenaert, Dr. Els Steeman, Professor

Ruth Piers, Dr. Peter Pype, Professor Wilfried Schnepp, en Professor Rudy Van den Broecke als

voorzitter. Bedankt voor uw betrokkenheid, uw waardevolle opmerkingen en goede suggesties die het

proefschrift echt verbeterden.

Ik wil ook heel graag mijn collega’s van het UCVV en onze vakgroep van nu en van vroeger bedanken.

Eén voor één zijn jullie fantastische mensen die met een gedrevenheid, nieuwsgierigheid en ambitie

zoeken naar inzichten en oplossingen voor erg diverse en indrukwekkende probleemstellingen. Een

bijzonder woord van dank gaat daarbij uit naar mijn directe bureaugenoten van het eerste uur (toen nog

in blok A), Joline, Ineke, Aurélie, Mathieu, en Veerle, en van het laatste uur (nu op 5K3), Veerle, Katrin

en Elien. Bedankt voor de manier waarop we altijd met de nodige humor de lastigste situaties aangepakt

hebben, hoe we oplossingen ‘uitdoctorden’, hoe we op elkaar rekenden voor ‘reality checks’, hoe jullie

konden appreciëren welke enorme culturele verrijking de aanwezigheid van een West-Vlaming met zich

meebrengt, en hoe we voor elkaar kleine fanclubs konden vormen.

Ik wil ook graag mijn collega’s van de VIVES Hogeschool, campus Roeselare, bedanken. Ik ben

dankbaar dat ik een deeltje mag uitmaken van een mooi team dat met een heldere visie over wie we

Dankwoord

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zijn als verpleegkundigen en wat we kunnen betekenen als verpleegkundigen, haar bacheloropleiding

vormgeeft. Een bijzonder woord van dank gaat daarbij naar Bart Debyser en Tineke De Backer. Het

onderzoek over Grensoverschrijdend Gedrag is bij jullie gestart. Ik mocht meewerken en verder werken

met jullie ideeën over grensoverschrijdend gedrag en wat zich dan afspeelt in zorgrelaties. Bedankt dat

ik hiertoe de kans kreeg, en bedankt voor jullie vertrouwen.

Ook mijn collega’s in de thuisverpleging wil ik heel graag bedanken: mama, Carine, en collega’s.

Bedankt dat ik ook een deeltje van jullie team mag uitmaken. Mijn betrokkenheid in de thuisverpleging

is de laatste tijd verminderd. Het neemt niet weg dat het zorgdragen voor de mensen van onze rondes,

en het rondrijden in onze streek altijd een beetje voelt als thuiskomen. Bedankt voor jullie impliciete en

expliciete steun.

In het bijzonder wil ik ook alle betrokken patiënten, hun naasten, en de betrokken verpleegkundigen,

danken dat zij hun gevoelens, gedachten en ervaringen met ons hebben willen delen. Praten over

ervaringen en percepties van agressie en grensoverschrijdend gedrag is niet vanzelfsprekend. Bedankt

dat jullie jullie verhalen met ons wilden delen.

De studenten uit de masteropleiding Verpleegkunde en Vroedkunde wil ik ook graag bedanken. Bedankt

voor jullie insteek, jullie feedback, jullie kritische vragen, … tijdens de jaren van mijn

assistentenmandaat. Een speciaal woord van dank gaat daarbij ook uit naar de studenten die op een

mooie manier zijlijnen uitwerken of uitwerkten van dit doctoraatsonderzoek.

Mijn vrienden en vriendinnen wil ik ook graag bedanken voor de nodige afleiding en het amusement.

Bedankt voor de vele leuke en knettergekke momenten samen. Bedankt voor het tonen van

belangstelling ookal was mijn relaas soms geweldig saai, bedankt voor het meeleven met mij, en jullie

steun!

Dan wil ik ook graag mijn familie bedanken. Bedankt lieve pepe, nichten, neven, tantes en nonkels!

Bedankt voor alle babbels, begrip, ontspanning, plezier, steun, en aanmoedigingen. Ik mag me gelukkig

prijzen in onze gezellige familie. Mijn dank is groot!

Mijn schoonfamilie wil ik ook graag bedanken. Ik heb veel geluk om me te mogen omringd weten door

stuk voor stuk fantastische mensen. Bedankt, lieve schoonmama, lieve schoonzussen en –broers, lieve

neefjes en nichtjes. Het is een eer om een deeltje uit te maken van jullie warme en grote familie. Bedankt

voor jullie ondersteuning gedurende dit ganse proces.

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Een heel speciaal woord voor onze mémé, Julia D’Haene. Lieve meme, elke dag nog ben je in onze

gedachten. Elke dag nog voorzie jij inspiratie, moed en kracht om verder te zetten. Herinneringen aan

jou doen ons verder doen met een gemis in ons hart maar met een kracht die alleen jij kon

teweegbrengen.

Een bijzonder woord ook voor mijn ouders. Lieve mama en papa, met enkele woorden hier kan ik niet

genoeg uitdrukken hoe dankbaar ik ben. Jullie hebben ons opgevoed met een respect voor traditie en

waardigheid. Met een gezonde portie zelfrelativering, en een nog gezondere portie geweldig droge

humor. Dat ik hier mag staan, heb ik aan jullie te danken. Jullie zetten ons op weg, kijken toe hoe we

dat doen, in een vertrouwen dat we onze weg vinden. Bedankt voor jullie steun bij de avonturen die wij

aangaan, en voor jullie meeleven met alle grote en kleine dingen in ons leven!

Mijn broers, Bram en Martijn, en Sofie als fantastische vriendin van Bram, wil ik ook graag bedanken.

Mijn broers en partners in crime. Het is een feit dat we zo van elkaar verschillen dat we perfect bij elkaar

passen. Bedankt voor jullie steun, jullie grapjes, jullie betrokkenheid!

Een laatste woord van dank is voor Filiep. Lieve Filiep, mocht ik je minder graag zien, dan zou het vast

makkelijker zijn om er over te babbelen. Bedankt voor de moed en kracht die je gaf, voor de

ondersteuning die je voorzag, om er te zijn wanneer ik je het meest nodig had, voor het geduld dat je

had, voor het doorgeven van discipline en veerkracht, en voor de rust die je bracht. Bedankt, Iepje!

Door de ondersteuning van velen mocht ik vandaag een droom verwezenlijken. Ik hoop nu dat ik zelf

kan bijdragen om anderen te helpen hun dromen te verwezenlijken. Ik wens u allen te bedanken voor

uw aanwezigheid, voor uw steun, en voor uw interesse!

Tina Vandecasteele, 18 januari 2018

Dankwoord

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Dankwoord

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AGGRESSION AND TRANSGRESSIVE BEHAVIOUR IN CARE RELATIONSHIPSInfluencing factors and underlying processes in nurses’ and patients’ perceptions

Tina Vandecasteele

Aggression in health care is not a new problem. Aggression towards healthcare workers is prevalent and well recognized internationally as a complex problem. When compared to other caregivers, nurses appear to be at especial risk to encounter aggression due to the nature, duration and intensity of their care relationships with patients. Research pointed out that aggression in care relationships generates several negative consequences for nurses, for patients, for the quality of care, and for the organisation as a whole.

This doctoral dissertation tried to contribute to the extant knowledge on what occurs in nurse-patient care relationships in a context of aggression and transgressive behaviour. Even though aggression as a phenomenon in care relationships has been the subject of abundant research, a ‘novel’ approach was adopted for this dissertation. The onset and meaning of ‘transgressive behaviour’ in care relationships was explored. This was done by quantitatively examining nurses’ experiences and perceptions of aggression, and by qualitatively studying what transgressive behaviour is for patients, means for nurses, and causes in nursing teams. The findings underline the complexity and multidimensional nature of aggression and transgressive behaviour in care relationships. In addition, behaviour in itself does not determine ‘what’ is experienced as aggressive or transgressive behaviour. Underlying dynamic processes in patients’ and nurses’ perceptions were identified that determine the meaning that is attributed to specific interactions in care relationships.

The findings of this dissertation offer patients, student-nurses, nurses and nursing managers a comprehensible framework of what occurs in nurse-patient care relationships when aggression or transgressive behaviour is experienced or perceived. The findings can provide content (or form the basis) of a policy to clarify, understand and remedy aggression and transgressive behaviour in practice.

Aggression and transgressive behaviour in care relationships between nurses and patientswas written as a PhD-thesis by Tina Vandecasteele at the Ghent University, Department of

Public Health, University Centre for Nursing and Midwifery.

Documents

AGGRESSION AND TRANSGRESSIVE BEHAVIOUR IN CARE