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Nursing and Health Sciences (2015), 17, 307312

Research Article

Nursing management of aggression in a Singapore

emergency department: A qualitative study
Mei Fen Tan, BSc (Nursing) (Hons),1 Violeta Lopez, RN, PhD2 and Michelle Cleary, RN, PhD3
1
Neuroscience Intensive Care, Tan Tock Seng Hospital, 2Alice Lee Centre for Nursing Studies, Yong Loo Lin School of
Medicine, National University of Singapore, Singapore and 3School of Nursing and Midwifery, University of Western
Sydney, Sydney, New South Wales, Australia

Abstract In Singapore, anecdotal evidence suggests that nurses are concerned about managing aggressive incidents in
the emergency department. In this study, registered nurses perceptions of managing aggressive patients in an
emergency department were explored. Ten registered nurses from the emergency department of an acute
public hospital in Singapore were interviewed. Four overarching themes emerged from the thematic analysis:
(i) impact of aggressive patients on nurses; (ii) nursing assessment of aggressive behaviors; (iii) nursing
management of aggressive behaviors; and (iv) organizational support and responsiveness. Further research is
required to better support nurses to deliver optimal care for aggressive patients and achieve positive and
effective outcomes.

Key words aggression, education, emergency department, management, nurse, Singapore.

INTRODUCTION 2010); for example, ED nurses in Taiwan report that restrict-

ing visitors access to ED leads to physical aggression (Tang
Workplace aggression refers to incidents where employees
et al., 2007).While aggression-management training is recom-
are abused, threatened or assaulted or subjected to other
mended for nurses, evidence suggests that the implementa-
offensive behavior in circumstances related to their work
tion of a one-time aggression training program is inadequate,
(Martino, 2003, p. 5). Aggression in the healthcare sector has
and that the content could be more practical (Delaney et al.,
been a concern for many years, especially among the nursing
2001; Pich et al., 2010).
profession. Globally, one-third of the nursing population
In Singapore, the nursing profession is predominantly
experience some form of workplace aggression in any
female, there is a shortage of registered nurses (RN), and the
12 month period, two-thirds of nurses experience non-
nursing workforce has a strong work ethic, typically working
physical violence, and one-quarter experience sexual harass-
long hours to meet tight deadlines (Cleary et al., 2013a,b).
ment (Spector et al., 2014).
According to Gantz et al., (2012), Singapore has a younger
The emergency department (ED) is noted as a high-risk
nursing workforce than in most developed countries, and
area for workplace aggression. For example, in Australia,
there is substantial attrition of nurses within the first three
emergency nurses reported 110 episodes of violence within a
years of their career related to the less-than-ideal working
5 month period, with 37% occurring on the evening shift
environment. Anecdotal evidence suggests there is an
(Crilly et al., 2004). Research shows, ED nurses experienced
absence of policy in support of an aggression-free workplace
physical injuries resulting in psychological effects, such as
(zero-tolerance legislation, prevention strategies, and manda-
anger, burnout, stress, anxiety, and fear (Gillespie & Melby,
tory training in aggression management), which differs to
2003; Needham et al., 2005). Nurses were concerned about
many Western nations (Pich et al., 2010).
their perceived inability to predict patients behaviors and
There is also a paucity of research in relation to patient-
future violent incidents (Canbaz et al., 2008).
related aggression toward nurses, especially in ED. Research
A review of the literature found that a sense of apathy
by Chan et al. (2013) found that patient and/or relative
by nurses or their managers has contributed to the under-
aggression is the most common type of work-related aggres-
reporting of workplace aggression (Pinar & Ucmak, 2010;
sion experienced by healthcare workers. A peer-help,
Wolf et al., 2014). Deficits in administrative and policy-based
multicomponent crisis response-management system has
practices are also noted (Choiniere et al., 2010; Pich et al.,
been made available by the Ministry of Health to Singapore
public general hospitals since 2008, but a multisite healthcare
workers survey by Chan and Chan (2012) revealed that only
Correspondence address: Michelle Cleary, School of Nursing and Midwifery, Univer-
10.6% of nurses have used the system to seek emotional
sity of Western Sydney, Locked Bag 1797, Penrith, NSW 2751, Australia. Email:
m.cleary@uws.edu.au support for work-related aggression. To date, there is only
Received 10 July 2014; revision received 13 October 2014; accepted 31 October 2014 one research study that actually focused on aggression in

2015 Wiley Publishing Asia Pty Ltd. doi: 10.1111/nhs.12188

308
Singapore (Yusuf et al., 2006); the restricted scope of the
investigation (verbal aggression and psychiatric hospital)
limits the applicability of the findings to other general
hospitals.
ED are a high-risk area for aggression, and abuse toward
nurses is relatively common, accepted as part of the job, and
embedded in the culture (Pich et al., 2010). Current evidence
points to the need to further explore nurses perspectives of
how best to care for people exhibiting aggressive behaviors,
which could contribute to efforts in reducing the adverse
effect on nurses and identify the impediments for the
required changes by organizations or individual healthcare
professionals (Cohen et al., 2013; Hahn et al., 2012; Needham
et al., 2005; Pich et al., 2010). It is against this background that
the present Singaporean study was developed. In this study,
ED nurses perceptions of managing aggressive patients were
explored. Although there have been a number of studies that
have focused on the impact of patients aggressive behaviors
in nurses, this qualitative study is the first in Singapore to
explore nurses perceptions of managing aggressive patients
presenting to the ED.
METHODS
The setting for this study was a 24 h ED at a major Singapore
general acute hospital, with separate ED facilities for adult
and pediatric patients. The inclusion criteria were RN who
had prior contact with aggressive patients and had worked in
the adult ED setting less than three months.
For the protection of human participants, approval for this
study was obtained from the National Healthcare Group
Domain Specific Review Board. Advertisement flyers and a
staff briefing were used to recruit potential participants. Inter-
views were arranged at a mutually-agreed venue and time,
and all participants provided written consent after they all
understood the nature and purpose of the study. The inter-
view guide was adapted from a previous study (Delaney
et al., 2001), with permission granted before being piloted
with two colleagues. Interview topics included demographics,
assessment of aggression, nursing interventions, communica-
tion skills, education and training, de-escalation and physical
restraint skills, post-aggressive incident support and follow
up, and other issues or relevant factors.
The interviews were conducted in English and all were
digitally recorded, with each lasting between 30 and
60 minutes. The principle of data saturation was adopted to
establish sample size; that is, until interview content became
repetitive and unlikely to generate new information from
further data collection (Morse & Field, 1996).
Data collection and analysis proceeded simultaneously
(Coffey & Atkinson, 1996). Verbatim transcriptions of the
data were analyzed according to the tenets of thematic analy-
sis and included becoming familiar with the data, generating
initial codes, searching for and reviewing themes, defining
and naming themes, and producing the report (Braun &
Clarke, 2006). These steps provided a systematic process for
the researcher to conduct the thematic analysis and develop
themes from the interview data.
2015 Wiley Publishing Asia Pty Ltd.
M. F. Tan et al.
RESULTS
Ten RN aged 2230 years were interviewed, and eight (80%)
were female. The participants had spent their entire nursing
career in the ED, and had 28 years of working experience.
Three (30%) participants were diploma holders, four (40%)
had an advanced diploma, and three (30%) had attained a
bachelor degree as their highest nursing qualifications at the
point of data collection. The thematic analysis yielded four
themes: (i) impact of aggressive patients on nurses; (ii)
nursing assessment of aggressive behaviors; (iii) nursing man-
agement of aggressive behaviors; and (iv) organizational
support and responsiveness.
Impact of patients aggressive behaviors on nurses
ED nurses reported that caring for aggressive people
affected them psychologically and physically. The psychologi-
cal effects included feeling upset, not feeling appreciated, and
having recurrent thoughts about what could be done better.
The frequent exposure to aggression created job dissatisfac-
tion, resentment, and regrets about initiating the interaction
with the person. Some of the nurses also reported feeling
burned out and wearisome about continuing with their work
duties:
I was punched . . . it was quite painful. So I kept thinking
what can I do better? Why must I go and attend to that
patient? Sometimes I feel like I should just ignore that
person. (Participant 3)
Fracture was also reported as a consequence of aggression,
and the majority of nurses were not always able to prevent
aggressive incidents. As a result of the physical injuries sus-
tained, nurses were not always able to complete their nursing
duties and were required to take sick leave.
Nursing assessment of aggressive behaviors
An integral part of managing aggression is the ability of
nurses to employ various nursing-assessment strategies. In
this study, nurses during their clinical encounter with aggres-
sive people used presenting information and previous
history, as well as nurses reflection on past experiences to
assess the person. They also relied on the medical diagnoses
(i.e. alcohol intoxication, delirium) to determine the possibil-
ity for aggressive behavior. All interviewees indicated that
alcohol intoxication contributed to a higher likelihood of
aggressive behaviors. Nurses also attributed possible under-
lying medical conditions, such as sepsis, electrolyte imbal-
ances, heat stroke, dementia, and seizures, to aggressive
behavior. Several nurses also reported that if they receive
information on a patient admitted with a drug overdose or a
risk of self-injury during the handover of care, they would
consider these patients to be potentially aggressive. Nurses
also used their observation skills as part of the routine assess-
ment for potentially-aggressive people. Specifically, nurses
observed body language, verbal cues, and signs of unhappi-
ness or dissatisfaction via the content, tone, and volume of
the patients speech:
Nursing management of aggression
You can observe their behavior is a bit abnormal when a
patient starts to shout and (they) dont obey your com-
mands. Potentially, they will be difficult to manage.
(Participant 10)
The nurses were quick to determine that those with the
aforementioned presentations would have some form of risk
for aggression in addition to being regular users of the ED:
I already know that this patient tends to be aggressive,
because they already have a history, or I have already
seen them being aggressive . . . we have regular patients,
drunk patients, who regularly turn up in our department.
(Participant 9)
The nurses reported making quick judgements to categorize
patients, as the use of chemical or physical restraints might be
necessary to effectively manage aggressive incidents.
Nursing management of aggressive behaviors
Despite sustaining injuries, nurses spoke about their profes-
sional obligations and the importance of upholding standards
and good service. These nurses also reported making extra
efforts to interact with aggressive people, even when they
were reluctant to do so:
You need to . . . be nice to them, but not too nice (to the
extent) you do everything for them . . . just be nice to
them, do whatever you need to do. (Participant 1)
Caring for aggressive people was deemed to be time inten-
sive. As a result, the majority of nurses believed that they
could not do what they should do for all persons in their care.
Across all the interviews, nurses adopted a stoic stance on the
issue of aggression, and viewed dealing with aggressive inci-
dents to be part of their job. Nurses perceived that they could
manage the challenges of caring for aggressive people,
despite the potential for physical or psychological injury:
Im not affected that much, because I think it (aggres-
sion) is normal inside ED, and people come in with these
kinds of conditions. (Participant 2)
However, some nurses reported instances where they or their
colleagues were unable to maintain professionalism:
Of course, at the scene, we are very angry . . . We . . .
shout at the patient: Hey you dont you must obey
us. (Participant 3)
Nurses had proactively offered to take over the responsibility
for care in the few instances in which they observed their
colleagues being unable to maintain their professionalism
toward patients. Frequent interaction with patients was
deemed important to prevent aggression, including providing
information and updates. This included using hospital trans-
lators if language was deemed a communication barrier.
Chemical and physical restraints were used to manage
aggression to ensure safety and allow the healthcare staff to
carry out important investigations and treatments. Nurses
309
also resorted to seeking help from the security department
when they were unable to satisfactorily manage the aggres-
sive situation:
We (nurses] call the security to come . . . You cant pos-
sibly sedate an alcohol-intoxicated patient because . . .
they will get more sedated . . . you cant physically
restraint them too, because they are . . . (still) conscious
and they are quite strong. (Participant 8)
Nurses reported contacting the police if it was perceived to
be a case of severe physical aggression or when the person
threatened the nurse. Nurses urged for changes so that they
were more supported:
I called (the police) to come and help me because it is a
very violent patient in the department. So after taking
down my report . . . they asked me, Do I want to pursue
the matter? . . . I was thinking . . . why am I given a
choice to pursue this matter? Cant they choose to
pursue them instead of me charging him for doing all
these violence and vulgarities? Because if I pursue this
matter, they told me, it is under civil law and I sue him
accordingly. (Participant 7)
It was also noteworthy that other than managing aggressive
incidents, nurses also needed strategies to be able to let go of
negative emotions. Many nurses explained that their coping
strategies had helped, and examples they gave included
venting to colleagues and family, separating professional
duties from ones personal life, and engaging in regular
leisure activities.
Organizational support and responsiveness
According to the ED nurses, debriefing sessions conducted
after incidents were infrequent, and sometimes there were
none at all. For incidents that were perceived as inconsequen-
tial, nurses reported that the nurse managers did not show
concern or render support. Inconsequential incidents
appeared to be justified and normalized by the high fre-
quency of aggressive incidents. Most of the nurses sought
support from colleagues counseling each other to cope
with the emotional effects. They expected front-line leaders,
such as senior nurses, to have the competency to manage
aggressive incidents and to be their role models:
I need the help of my senior nurses to teach me . . . how
to properly manage (aggressive patients) or how to
decide what interventions to use (in aggression manage-
ment). (Participant 4)
Besides senior nurses, male nurses tend to step forth to assist
in aggressive incidents. Not all nurses reported being familiar
with the available guidelines, policies, and procedures that
could help them manage aggressive incidents. It was sug-
gested that the guidelines should provide a systematic form
of assessment to identify people who can potentially turn
aggressive. However, current guidelines, protocols, and poli-
cies provided directions on when to call the police and seek
help. It appears that most nurses filed police reports when
they received verbal threats from their patients:
2015 Wiley Publishing Asia Pty Ltd.
310
One patient said: You dont let me see you outside the
hospital. Ill kill you if I see you. So because of this case,
we made a police report. Because it is (a) threat and you
wont know if he really will come back and kill you,
because he can just wait outside for you in (this hospi-
tal), then . . . follow you home. (Participant 6)
As part of the EDs protocol, it was mandatory for nurses to
write incident reports for incidents of physical aggression.
Similar to incidents of verbal aggression, nurses reported that
the decision to complete a report was at their discretion.
Across all interviews, nurses believed that incident reports
were important and necessary to avert legal liabilities in the
event of alleged negligence or complaints against the nurse:
Because the patient is threatening us . . . we really have
to do write something in the incident report . . . if ever
the patient sues us or writes a complaint letter, we have
this written report of what really happened that time,
that day. (Participant 5)
Despite the importance of incident reporting, nurses found
the process cumbersome. They also perceived that manage-
ment rarely acted on reports or provided additional
resources to support nurses in managing aggressive incidents.
Workplace education, preparation, and training were
deemed important to prepare nurses in ED for their role in
managing aggressive behaviors. Some nurses stressed the
importance of actual workplace experience in gaining skills,
knowledge, and confidence:
I think the experience gained from working here will
help you . . . It is better than any course . . . there is no
course that can teach you. It is just valuable experience.
(Participant 6)
DISCUSSION
ED nurses experiences of the impact of patients aggression,
as well as their perceptions of managing aggressive patients,
were explored in this study.The findings resonated with many
other studies about the myriad of consequences ED nurses
experience from aggressive encounters (Gillespie & Melby,
2003; Zampieron et al., 2010). Nurses in this study reported
bodily injuries (e.g. being hit, kicked, and pushed), and ver-
balized reluctance in caring for aggressive people, although
acknowledging their professional obligation to care for such
people.The findings regarding these negative effects resonate
with the literature, including feeling burned out (Gillespie &
Melby, 2003; Lau et al., 2012; Lo et al., 2012; Chan et al., 2013;
Kowalenko et al., 2013).
The nurses were able to identify potentially-aggressive
people when they factored the patients medical or non-
medical presentation into account. The findings of this study
are supported by previous research. Alcohol intoxication, the
use of drugs/drug overdose, as well as the presence of mental
illness were cited by nurses as contributing to aggressive
incidents (Crilly et al., 2004). Similarly, nurses cited medical
conditions as biomedical cues to determine the aggression
risk of patients. Health service-related reasons, such as long
waiting times or patients seeking ED admission due to socio-
2015 Wiley Publishing Asia Pty Ltd.
M. F. Tan et al.
economic reasons, could also result in patients exhibiting
aggressive behaviors. Previous research has reported similar
findings, where nurses perceived that people who could not
tolerate the long waiting times were potential aggressors
(Wong et al., 2007; Wolf et al., 2014). This problem is also
attributed to the current setting in this study, where waiting
times to see a doctor could vary between 4 and 10 h. Strate-
gies to decrease waiting times are currently being reviewed in
this setting.
In this study, nurses also depended on the recall of past
experiences to identify potential aggressors. These were
people whom they have had previous aggressive encounters
with. Observation skills were particularly useful for nurses in
this study in identifying behavioral cues for potential aggres-
sors. It might be useful if ED nurses in Singapore consider
formal assessment tools to guide their assessment for aggres-
sion risk, and this warrants further consideration.
Nurses in this study perceived the care of aggressive
people as part of their everyday work duties; this was justified
by the common occurrence of aggression in their workplace.
The challenge for ED nurses was maintaining their profes-
sionalism during an aggressive encounter. As part of their
professional code, nurses are required to embody core values
of care and empathy, although it might prove difficult to
express naturally in non-ideal situations (Zapf, 2002; Spector
et al., 2014), especially when dealing with people who might
not be appreciative of the nurses efforts.
Nurses urged for the development of resources in order to
help them cope with the challenges in the workplace, and
they valued security and police as aggression-management
resources. Similar to previous studies, nurses reported that
most of the security guards were quick in their arrival and
assisted the nurses during aggressive incidents (Gillespie
et al., 2012). However, more organizational efforts are
needed in ensuring a reliable security workforce that can
readily assist in aggressive incidents.
As demonstrated in the findings, nurses acquired
aggression-management skills by learning from other more
experienced nurses when transitioning to the workplace as
graduate nurses. The benefits of role modeling are noted in
the literature (Omansky, 2010; Cleary et al., 2013). Nurses
recommended aggression-management training programs to
enhance their confidence, as well as the need to strengthen
current induction programs. Most of the nurses mentioned
the use of current guidelines, protocols, and policies in
guiding their nursing care of aggressive patients in this study.
However, they expressed a need for further organization
support to enhance the available support and network system
for staff who encounter or work with aggressive patients,
including the provision of a formal debriefing system.
Study limitations
As with all studies, there are a number of limitations for this
research project. The project was conducted at a single site
with a small group of ED nurses. Further, findings explored
registered nurses experiences in one emergency department
in Singapore, and therefore, are restricted in scope and trans-
ferability, especially in Western countries.
Nursing management of aggression
Implications for nursing practice
Consistent with international reports, workplace aggression
appears to be relatively common in the ED and needs to be
addressed to avert its physical and psychological effects on
nurses, as well as other healthcare workers in the ED. In this
study, nurses awareness of patients who might be potentially
aggressive was mainly based on past experiences. However,
there is a need for a more reliable and valid way of assessing
these patients, and such a tool should be used as part of a
routine assessment of all patients presenting in the ED. The
study also highlights the need for more thorough education
programs, not only to prepare nurses in handling aggression at
the workplace, but also other work-related crises. Such pro-
grams must be well structured, evidence based, and multidis-
ciplinary focused, and should be provided during the
orientation of new healthcare workers and as needed. Man-
agement is also encouraged to provide a supportive environ-
ment for staff who experience aggressive behaviors, so as to
encourage staff to report all incidents and be assured that they
will be acted upon. The long waiting times of patients in the
ED are a worldwide problem that contributes to aggression.
All ED should explore the factors that contribute to the long
waiting times and implement strategies to improve the flow of
patients more effectively. The role of the multidisciplinary
team, including security officers, must also be acknowledged
and warrants further exploration and research.
Conclusion
This study has contributed to the understanding of ED
nurses experiences of the physical and psychological effects
of having to care for aggressive patients. Similar to other
studies, the nurse participants reported aggressive incidents
to be relatively common in the ED. Despite being at the
receiving end of aggression, the nurses held strongly to their
professional role and responsibilities. Support from col-
leagues was sought by participants, and formal workplace
debriefing and counseling were perceived to be lacking.
Nurses urged for more organizational support to mitigate
workplace patient aggression. Further discussion and
research are required to better support nurses to deliver
optimal care for aggressive patients, and to achieve positive
and effective outcomes.
ACKNOWLEDGMENTS
We would like to thank Dr Lau Ying for her assistance with
obtaining the ethics approval, Sister Tho Poh Chi, Sister
Liang Sufang, and Dr Siti Zubaidah for facilitating access to
the clinical area, and staff nurse Claudia Tan for her valuable
help during the recruitment phase of the study.
CONTRIBUTIONS
Study Design: MFT, MC.
Data Collection and Analysis: MFT, VL, MC.
Manuscript Writing: MFT, VL, MC.
311
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