BACKGROUND: There is a high incidence of assault against nursing staff in mental health care. Efforts to reduce the incidence of assault are hindered by the complexity and nature of the problem and by the fact that incidents of assault are underreported. OBJECTIVE: To identify factors influencing nurses to report staff assault by patients in an inpatient mental health care facility. DESIGN: The study used a modified nominal group technique in which nurses worked together to identify themes in decisions about reporting incidents of assault. The participants were nurses at two sites of a mental health care organization. RESULTS: Nurses used a complex decision-making process to decide whether an incident of assault was worth reporting. Safety culture, the design of the incident reporting system, and the effect on patients were important components of the decision-making process. CONCLUSION: Strategies that consider all levels of the organization’s system should be used to improve reporting of assault incidents.
Abderhalden, C., Needham, I., Dassen, T., Halfens, R., Haug, H., & Fischer, J. ( 2008). Structured risk assessment and violence in acute psychiatric wards: Randomised controlled trial. British Journal of Psychiatry , 193, 44-50.
2.
Aspinal, F., Hughes, R., Dunckley, M., & Addington-Hall, J. (2006). What is important to measure in the last months and weeks of life? A modified nominal group study . International Journal of Nursing Studies, 43, 393-403.
3.
Barach, P., & Small, S. ( 2000). Reporting and preventing medical mishaps: Lessons from non-medical near miss reporting systems. British Medical Journal , 320, 759-763.
4.
Baumann, A., Underwood, J., Blythe, J., Ciliska, D., Ehrlich, A., Akhtar-Danesh, N., . . . Dragan, A. ( 2006). Better data: Better performance. Community health nursing in Ontario (Health Human Resources Series No. 7). Retrieved from http://www.nhsru.com/documents/Series%207%20Community%20Health%20Nursing.pdf
5.
Black, N. ( 2006). Consensus development methods. In C. Pope & N. Mays (Eds.), Qualitative research in healthcare (pp. 132-141). Malden, MA : Blackwell.
6.
Cullen, D.J., Bates, D., Small, S.D., Cooper, J.B., Nemeskal, A., & Leape, L.L. ( 1995). The incident reporting system does not detect adverse drug events: A problem for quality improvement. Joint Commission Journal of Quality Improvement, 21, 541-548.
7.
Delbecq, A.L., Van de Ven, A.H., & Gustafson, D.H. (1975). Group techniques for program planning. Glenview, IL: Scott Foresman .
8.
Delaney, J., Cleary, M., Jordan, R., & Horsfall, J. ( 2001). An exploratory investigation into the nursing management of aggression in acute psychiatric settings. Journal of Psychiatric Mental Health Nursing, 8, 77-84.
9.
Delaney, K.R., & Johnson, M. ( 2006). Keeping the unit safe: Mapping psychiatric nursing skills . Journal of the American Psychiatric Nurses Association, 12, 198-207.
10.
Duxbury, J., & Whittington, R. (2005). Causes and management of patient aggression and violence: Staff and patient perspectives. Journal of Advanced Nursing, 12, 198-207.
11.
Edmondson, A. ( 2004). Learning from failure in health care: Frequent opportunities pervasive barriers. Quality & Safety in Healthcare, 13(Suppl. 2), ii3-ii9.
12.
Evans, S., Berry, J., Smith, B., Esterman, A., Selim, P., O’Shaughnessy, J., & DeWit, M. ( 2006). Attitudes and barriers to incident reporting: A collaborative hospital study. Quality & Safety in Health Care, 15, 39-43.
13.
Ferns, T., & Chojnacka, I., (2005). Reporting incidents of violence and aggression towards NHS staff. Nursing Standard, 19, 51-56.
14.
Firth-Cozens J. ( 2001). Cultures for improving patient safety through learning: the role of teamwork. Quality & Safety in Healthcare, 10(Suppl. 2), ii26-ii31.
15.
Fry, A., O’Riordan, D., Turner, M., & Mills, K. ( 2002). Survey of aggressive incidents experienced by community mental health staff. International Journal of Mental Health Nursing, 11, 112-120.
16.
Gaba, D. ( 2000). Structural and organizational issues in patient safety: A comparison of healthcare to other high-hazard industries. Californian Management Review, 43, 83-102.
17.
Gerberich, S.G., Church, T.R., McGovern, P.M., Hansen, H.E., Nachreiner, N.M., Geisser, M.S., . . . Watt, G.D. (2004). An epidemiological study of the magnitude and consequences of work-related violence: The Minnesota Nurses’ study . Occupational and Environmental Medicine, 61, 495-503.
18.
Gordon, J., Gordon, L., & Gardner, D. ( 1996). A study of assaultive/aggressive behaviour on staff by patient/clients in psychiatric facilities. Journal of Occupational Health and Safety-Australia and New Zealand, 12, 169-177.
19.
Haller, R.M., & Deluty, R.H. ( 1988). Assaults on staff by psychiatric in-patients. British Journal of Psychiatry, 152, 174-179.
20.
Hammond, S.A. ( 1996). The Thin Book of appreciative inquiry. Plano, TX: Thin Book.
21.
Hesketh, K., Duncan, S., Estabrooks, C., Reimer, M., Giovannetti, P., Hyndman, K., & Acorn, S. ( 2003). Workplace violence in Alberta and British Columbia hospitals . Health Policy, 63, 311-321.
22.
Holden, R., & Karsh, B.-T. ( 2007). A review of medical error reporting system design considerations and a proposed cross-level systems research framework. Human Factors, 49, 257-276.
23.
Johnson, C.W. ( 2003). Failure in safety-critical systems: A handbook of accident and incident reporting. Glasgow, Scotland: University of Glasgow Press.
24.
Johnson, M. ( 2004). Violence on inpatient psychiatric units: State of the science. Journal of the American Psychiatric Nurses Association , 10, 113-121.
25.
Johnson, M., & Delaney, K. ( 2006). Keeping the unit safe: A grounded theory study. Journal of the American Psychiatric Nurses Association, 12, 13-21.
26.
Kidd, B., & Stark, C. ( 1992). Violence and junior doctors working in psychiatry. Psychiatric Bulletin of the Royal College of Psychiatry, 16, 144-145.
27.
Kingston, M., Evans, S., Smith, B., & Berry, J. ( 2004). Attitude of doctors and nurses towards incident reporting: A qualitative analysis. Medical Journal of Australia, 181, 36-39.
28.
Kling, R., Yassi, A., Smailes, E., Lovato, C., & Koehoorn, M. ( 2009). Characterizing violence in health care in British Columbia . Journal of Advanced Nursing, 65, 1655-1663.
29.
Lanza, M., Zeiss, R., & Rierdan, J. ( 2009). Multiple perspectives on assault: The 360 degree interview . Journal of the American Psychiatric Nurses Association, 14, 413-420.
30.
Lawton, R., & Parker, D. ( 2002). Barriers to incident reporting in a healthcare system . British Medical Journal, 11, 15-18.
31.
Leonard, M., Graham, S., & Bonacum, D. ( 2004). The human factor: the critical importance of effective teamwork and communication in providing safe care. Quality & Safety in Healthcare, 13(Suppl. 1), i85-i90.
32.
Levine, D., Saag, K., Casebeer, L., Colon-Emeric, C., Lyles, K., & Shewchuk, R. ( 2006). Journal of the American Medical Directors Association , 7, 420-425.
33.
Lion, J., Snyder, W., & Merrill, G. ( 1981). Underreporting of assaults on staff in a state hospital . Hospital & Community Psychiatry, 32, 497-498.
34.
Lipscomb, J., & Love, C. ( 1992). Violence toward health care workers: An emerging occupational hazard. American Association of Occupational Health Nurses Journal, 40, 219-228.
35.
Ludwig, B. ( 1997). Predicting the future: Have you considered using the Delphi Methodology?Journal of Extension, 35. Retrieved from http://www.joe.org/joe/1997october/tt2.php
36.
Meehan, T., McIntosh, W., & Bergen, H. ( 2006). Aggressive behaviour in the high-secure forensic setting: The perception of patients. Journal of Psychiatric and Mental Health Nursing, 13, 19-25.
37.
Molyneux, G., Wright, B., Rush, G., Reidy, J., Campbell, F., Ryan, M., . . . Ambikapthy, A. (2009). Psychiatric training- a dangerous pursuit . Psychiatric Bulletin of the Royal College of Psychiatry , 33, 189-192.
38.
Needham, I., Abderhalden, C., Meer, R., Dassen, T., Haug, H., Halfens, R., & Fischer, J. ( 2004). The effectiveness of two interventions in the management of patient violence in acute mental inpatient settings: Report on a pilot study. Journal of Psychiatric and Mental Health Nursing, 11, 595-601.
39.
Nolan, P., Dallender, J., Soares, J., Thomsen, S., & Arnetz, B. ( 1999). Violence in mental health care: the experiences of mental health nurses and psychiatrists. Journal of Advanced Nursing , 30, 934-941.
40.
Pope, C., Ziebland, S., & Mays, N. ( 2006). Analysing qualitative data. In C. Pope & N. Mays (Eds.), Qualitative research in healthcare (pp. 63-81). Malden, MA: Blackwell.
41.
Probst, T., Brubaker, T., & Barsotti, A. ( 2008). Organizational injury rate underreporting: The moderating effect of organizational safety climate. Journal of Applied Psychology, 93, 1147-1154.
42.
Reason, J. ( 2004). Beyond the organizational accident: The need for "error wisdom" on the front line. Quality & Safety in Health Care, 13, ii28-ii33. doi:10.1136/qshc.2003.009548
43.
Ryan, J., & Poster, E. ( 1989). The assaulted nurse: Short-term and long-term responses . Archives of Psychiatric Nursing, 3, 323-331.
44.
Schectman, J., & Plews-Ogan, M. (2006). Physician perception of hospital safety and barriers to incident reporting. Joint Commission Journal on Quality and Patient Safety, 32, 337-343.
45.
Stanhope, N.M., Crowley-Murphy, M., Vincent, C., & O’Connor, A.M. (1999). An evaluation of adverse incident reporting. Journal of Evaluation in Clinical Practice , 5, 5-12.
46.
Tuffrey-Wijne, I., Bernal, J., Butler, G., Hollins, S., & Curfs, L. ( 2007). Using Nominal Group Technique to investigate the views of people with intellectual disabilities on end-of-life care provision. Journal of Advanced Nursing, 58, 80-89.
47.
Vincent, C., Stanhope, N., & Crowley-Murphy, M. (1998). Reasons for not reporting adverse events: An empirical study. Journal of Evaluation in Clinical Practice, 5, 13-21.
48.
Vincent, C., Taylor-Adams, S., & Stanhope, N. ( 1998). Framework for analyzing risk and safety in clinical medicine . British Medical Journal, 316, 1154-1157.
49.
Waring, J. ( 2004). A qualitative study of the intra-hospital variations in incident reporting. International Journal for Quality and Safety in Healthcare, 16, 347-352.
50.
Waring, J. ( 2005). Beyond blame: Cultural barriers to medical incident reporting . Social Science & Medicine, 9, 1927-1935.
51.
Woods, P., Ashley, C., Kayto, D., & Heusdens, C. ( 2008). Piloting violence and incident reporting measures on one acute mental health inpatient unit. Issues in Mental Health Nursing, 29, 455-469.
52.
Wynne, R., Clarkin, N., Cox, T., & Griffith, A. ( 1996). Guidance on the prevention of violence at work. Luxembourg: European Commission.
