Lived Experience of Violence Perpetrated by Treated Patients and Their Visitors in Intensive Care Units: A Qualitative Study of Nurses

ABSTRACT Background Patient and visitor violence (PVV) is a widespread problem for health professionals. Nurses working in intensive care units (ICUs) face a relatively high risk of experiencing PVV, which significantly impacts both the health of nurses and the institution as a whole. The subjective perceptions of ICU nurses regarding PVV are inadequately explored in the literature. Purpose The purpose of this study was to explore the perspectives, experiences, and perceptions of PVV in ICU nurses and to better understand the precipitating factors of violence. Methods A phenomenological qualitative design and purposive sampling were used. A semistructured interview guide was used to conduct in-depth interviews with 12 ICU nurses with PVV experiences. Giorgi's method of analysis was used to discover and identify the essential categories of experience. Results Five main experience categories were identified: family and patient factors as flashpoints, managing suppressed emotions by weathering the emotional storm, spiritual awakening after violence, and strategies for surviving further violence. The participants' experiences with PVV included a range of caring and mental health difficulties. In ICU settings, patient progress is often unpredictable, resulting in discrepancies between patient/family expectations and reality. Because feelings of frustration and powerlessness can eventually cause exhaustion in ICU nurses, implementing effective emotional management, stress adjustment, psychological counseling, team support, and violence intervention programs are crucial. Conclusions/Implications for Practice This study provides new information on the process by which nurses can progress from inner trauma to self-recovery, moving from a negative affectivity disposition to a better understanding of threat appraisals and coping response options. Nurses should increase their awareness of the complexity of the phenomenon and of the interplay among the factors underlying PVV. The results of this study suggest that routine confusion and delirium assessments to rule out patients with ICU delirium in ICUs are important to preventing PVV. This study considers some of the implications of the research findings for nursing managers. Interventions, training programs, and/or management action should be used to ensure psychological and mental support is extended to all witnesses of PVV events and not only to those targeted by violence.


Introduction
Workplace violence (WPV) has become an increasingly serious problem in healthcare (International Labour Organization, International Council of Nurses, World Health Organization, & Public Services International, 2002) and is now a widespread public health and major occupational and health hazard for nurses (Gu et al., 2022;Karatuna et al., 2020;Kibunja et al., 2021). Violence has been shown to be as much as 4 times higher in healthcare than other professions (Occupational Safety and Health Administration, 2015). Despite the widespread public view that violence is not a solution to problems (81.2%) and that health professionals should not experience violence (65.9%), WPV against nurses has continued to increase (Döndü & Yasemin, 2021). WPV significantly affects the physical and mental health of health professionals as well as institutions as a whole (Kumar et al., 2019;Rayan et al., 2019). Policies and regulations have been formulated to prevent WPV, with multiple international organizations advocating zero tolerance of healthcare violence.
Work-related health hazards have been common and varied among nurses working in intensive care units (ICUs), representing a complex problem about which little is known (Chiou et al., 2013). In healthcare institutions, ICUs are the unit that experiences the highest prevalence of WPV, with 1 as many as 82.8% of ICU nurses experiencing at least one form of WPV (Park et al., 2015). Over a 12-month period, 48.5% of nurses reported physical violence, 61.4% reported threats of violence, and 75.8% reported verbal abuse (Park et al., 2015). In Taiwan, 55.5% of emergency department/ICU nurses experienced aggression, 30.5% of nurses reported physical violence, and 49.1% reported nonphysical violence over a 1-year period (Wei et al., 2016). Moreover, ICU nurses face the greatest risk of experiencing physical violence (Chiou et al., 2013).
Recent studies have also shown patient and visitor violence (PVV) against healthcare workers to be on the rise. PVV, classified as Type II WPV, is a dangerous occupational crisis. Certain healthcare settings are more prone to PVV than others. The findings of several studies indicate that health professionals working in ICUs often experience high levels of PVV (Hahn et al., 2013). ICU nurses are frequently exposed to PVV, although exposure to PVV has been underreported. Nurses are frequent targets of PVV.
The context of violence in ICUs differs from other forms of violence (Lee et al., 2015;Pol et al., 2019). Most violent incidents in ICU settings are perpetrated by patients (81.1%) and their families (40.2%). Patients, as compared with patient families, are more likely to be the perpetrators of physical violence (94.8% vs. 18.8%), threats of violence (90.9% vs. 31.4%), and verbal abuse (74% vs. 36%). They are also the largest perpetrators of sexual harassment incidents (58.7%; Park et al., 2015). However, the underreporting of PVV makes determining the actual extent and severity of the problem difficult.
A number of studies have focused on the consequences, emotional repercussions, and work impacts after experienced violence (Gu et al., 2022;Rayan et al., 2019). Nearly half (45.7%) of nurses working in ICUs and other related units have reported moderate-to-severe psychological distress (Huang et al., 2021). However, there is considerable variation in terms of the forms, sources, and nature of PVV among healthcare settings. Most research on WPV has been descriptive in nature and has adapted nonexperimental methods such as cross-sectional or retrospective survey designs with instruments used to assess prevalence. Few researchers have used qualitative methods to explore the lived experience of PVV. Moreover, qualitative data with respect to the antecedents and consequences of PVV in ICU nurses are insufficient. To address this issue and develop strategies to effectively reduce the risk of PVV in ICUs, accurate experiences reflecting the true extent of the problem are needed.
Very few studies in the literature have investigated the subjective perceptions of ICU nurses. Given the paucity of studies on PVV against ICU nurses, this qualitative study employed a phenomenological method to explore the perspectives, experiences, and perceptions of ICU nurses regarding PVV experienced in clinical practice. In addition, this study was also designed to explore the nature, extent, causes, and impacts of PVV directed against nurses and the situations (antecedents) and characteristics of the perpetrators in ICU settings.

Design
In-depth, semistructured interviews were used in this qualitative descriptive study. Data were collected to shed light on nurses' experiences of PVV, their judgment and needs in facing the violence, and the precipitating factors of violence.

Participants
Purposive sampling was used to recruit registered nurses working in ICUs. The inclusion criteria were as follows: working full-time and providing direct nursing care; being ≥ 20 years old; having experienced physical or verbal violence from patients, patient family members, or visitors; and agreeing to be interviewed. The study content and participation expectations were explained to potential participants by the researchers upon recruitment.

Interview Guide
The interview guide was developed to explore PVV incidents directed against the participants, the consequences of PVV, and the prevention of PVV in ICUs; to describe the underlying causes of these incidents; to determine how the participants typically evaluate their risk in confronting PVV during nursing care; and to assess whether and how the participants modified their attitudes or thoughts after experiencing PVV.

Data Collection
Interview data were collected in 2020. The researchers conducted the interviews after first talking with participants to establish rapport. The interviews were held in a private office in each participant's workplace and lasted for an average of 1 hour. Upon completion of the interview, the participants received a small gift for their time. Data saturation was reached when there was sufficient information to draw necessary conclusions, no new information was discovered in the data analysis, and no further insights were produced. Data saturation ensured that an integrated range of issues had been explored and that an adequate level of quality and content validity had been attained.

Rigor
All interviews were audio recorded, transcribed verbatim, and compared for accuracy. The concept of rigor in qualitative research was applied to the research process (Guba & Lincoln, 1989). Strategies for ensuring rigor were also built into the qualitative research process used. Reflexivity helps avoid researcher bias by encouraging examination of their role and how their personal levels of involvement impact the analysis (Cassell, 2015). In this study, all members of the research team had professional backgrounds and career experience in intensive care, mental health, public health, nursing, and medicine as well as training and experience related to violence-related qualitative research, which allowed them to perceive and understand WPV-related issues and the cognitive and emotional states of victimized ICU nurses. The researchers established credibility of the findings by using strategies such as extensive involvement, member checking, persistent observation, and triangulation. After each interview, the researchers listened repeatedly to the recording to ensure the accuracy of the transcription, descriptions of the participant's lived experience, and subjective perceptions of the PVV incident. The researchers' intense and prolonged involvement in the studied environment and with the participants is a strength of this study. One of the researchers was from the studied community, whose involvement facilitated intense and persistent observation and enhanced trust and rapport with the participants.
Member checking was used as a validation technique to ensure study credibility. Data were returned to the participants to check for resonance with their experiences and to make corrections if necessary. These checks and confirmation of no errors or discrepancies in the data increased confidence that the results adequately and accurately captured the dimensions and nature of the participants' experiences.
The researchers cross-checked the emerging categories with the verbatim transcriptions and took detailed notes outlining the analysis. Rigor was further strengthened by cross-checking the formulated categories with a neutral co-examiner (an experienced qualitative researcher) who received copies of the data and the central categories. The co-examiner returned a written analysis after testing the results and ensuring the accuracy of the analysis. The conclusions of the researchers and the co-examiner were all in agreement. This independent analysis by a co-examiner provided a significant credibility check on the categories identified from the interview data.

Data Analysis
Qualitative content analysis, which uses efficient and practical procedures to systematize and present the results of qualitative analyses, was used in this study. An inductive approach was also applied (Thomas, 2006) to condense the extensive raw textual data into concise categories, establish clear links between the categories and research purposes, and establish understandings or structure meanings through the development of categories.
All of the categories identified were derived from the data analysis. A rich presentation of the findings together with supporting quotations in the participants' own words were provided. For calibration and validity purposes, interviews were coded independently by the researchers followed by thorough and frequent peer debriefings and discussions of outcomes to obtain consensus. All of the data gathered were thoroughly examined, with each recurring category and important clue in each response highlighted to develop the coding frame. The words and phrases associated with PVV-related perceptions and experiences were coded.

Ethical Considerations
The protocol for this study was approved by the institutional review board at the participating hospital (Registered No. EMRP70108N). Participants were informed about the purpose of the study, the voluntary nature of their participation, and their right to stop or withdraw at any time. All of the information collected for this study was anonymized, and confidentiality was maintained.

Results
Twelve ICU nurses were recruited as participants. Their average age was 32 years, and most were female (n = 10, 83.3%), single (n = 8, 66.6%), held a university degree (n = 10, 83.3%), and had an average of 10 years of work experience (tenure). The most frequent type of PVV encountered was verbal violence.
All of the interviews were analyzed, and the concepts were extracted. The results were expressed in an integrated manner. Five categories and 14 subcategories were identified and are shown in Figure 1. Examples of the process used by the researchers to elicit results from the raw data are given in Table 1 in support of the quality of the analysis.

Family Factor as a Flashpoint
A patient's condition changing for the worse and expectations for recovery falling short of family expectations result in disappointment, particularly when the result is a patient death. Under these conditions, the affected families often turn their negative emotions into verbal or physical violence directed at nurses.

The discrepancy between reality and expectation
In this study, when families faced life-threatening emergencies or their loved ones experienced a worsening of their condition, and the situation did not conform to their expectations, they often found it difficult to cognitively accept why their expectations were not met. They exhibited negative emotions in various forms and refused to accept the facts of the patient's situation. Patient family members blamed nurses for the worsening condition of the patient, making nurses the targets of the families' emotional outbursts.
The son kept saying, how could it be? When we came to see her last time, she could still open her eyes and she looked fine. How could it change so quickly? I don't believe it. Did nurses not help my mother by draining her phlegm, turning her over, and feeding her? Did they make her become like this? (Nurse Helen)

Misunderstanding
Families perceived that nurses lacked empathy, which fueled their anger and contributed to violent outbursts.
…How can you be a nurse when you have such a bad attitude towards patients without compassion? My mom was already uncomfortable in bed with her hands tied so tightly. She wrote on the whiteboard that you threatened her, saying that if she moved again, she would be tied up for a long time..... I'm going to make a complaint to the hospital about you. (Nurse Iris) Violence in Intensive Care Units VOL. 31, NO. 4, AUGUST 2023 Attack as an emotional outlet Families experienced negative emotions such as sadness, loss, and anxiety in ICUs in different ways. Some families vented their negative emotions through violent behaviors. They shouted at and threatened nurses directly.
He [family] was screaming at the nursing stations.... His mood was getting more and more agi-tated…. He even raised his right hand, threatening to hit me. (Nurse Dana) I told him [family] that because of the heavy injury to his mother's brain, she was no longer breathing and had no pulse. However, I said that you could still speak to her. She might be able to hear you. As soon as I turned my back on him, he threw a punch at me and hit the ward partition. His looked furious. (Nurse Amy)

Patient Factor as a Flashpoint
Disease and symptoms improved, but still struggling Although patients in the ICU receive constant care, are regularly monitored by life support equipment, and receive medication to help improve bodily functions, they are still often agitated, confused, and uncomfortable. Their extremely uncomfortable conditions increase feelings of restlessness and anxiety, resulting in resistance and sometimes violent reactions.
He [patient] was agitated and anxious and kept kicking the bed. I asked him to stop kicking the bed. He complained that he couldn't take it anymore and kept kicking. To prevent his tube from slipping, I used a restraint band to tie his feet, as per the doctor's advice. He was so angry and kicked me in the face.

(Nurse Bella)
Lack of consensus Lack of consensus among patients and the healthcare team, including doctors and nurses, regarding the best course of treatment further complicated the decision-making process. Helping patients to accept a proposed treatment plan was found to be difficult, with rejection and hostility sometimes triggering violence.
After the patient was transferred to the general ward and discharged shortly afterwards, he went to the police station and filed a report on me. His complaints included unprofessional treatment in the ICU and so on. The patient adopted a hostile and provocative attitude and was angry and irritable. He sued me. (Nurse Bella)

Managing Suppressed Emotions by Weathering the Emotional Storm
Lack of respect Patients and/or families expressed doubts about the clinical care received and even engaged in verbal and physical violence, which made the nurses in this study feel disrespected.  Lack of respect was a factor causing patients/families to engage in violence against the nurses. In addition, persistent experiences of disrespect led to fear, anger, humiliation, and psychological distress in the nurses.
We [the treatment team] are dedicated to treating patients... I don't know why families think we treated the patient badly…. We have a terrible relationship with them. It hurts my self-esteem. (Nurse Karen) Intertwined nurse-patient relationship A good nurse-patient relationship creates a special bond between nurses and patients and/or their families. PVV in the ICU was shown to be associated with unfriendly or uncoop-erative attitudes from the patients/their families toward nurses. Expressions of agitation, restlessness, and unstable emotions further strained the nurse-patient relationship.
I really had a hard time accepting their negative attitude towards me. I felt helpless, and I didn't want to communicate with them any longer or try to understand the reasons behind their attitude. (Nurse Helen) Inner conflict-tension between emotion and responsibility Both physical and nonphysical violence caused harm and suffering to nurses. The nurses in this study experienced significant short-and long-term effects of violence, including fear and mood

Spiritual Awakening After Violence
The nurses in this study developed appropriate coping skills and positive attitudes after their exposure to WPV. They were able to reflect upon and recall the key elements involved in communication problems and PVV and attempted to undergo self-reflection and emotional adjustment.

Positive introspection
Self-reflection is the essential link between experience and learning. Nurses in this study learned to better handle their negative emotions through the thinking and learning process and thus maintained their professional capability in nursing care. The nurses changed their thinking introspectively, found ways to cope, and attempted to avoid similar incidents from recurring.
I need to be more careful in my interactions with patients. I often think, how can I handle things better? I have learned that when the situation is different from what I expected, I need to think about the discrepancy in expectations between nurses and patients or their families, and whether I need to change my normal way of doing things. I think that dealing with workplace violence requires a different approach. (Nurse Carol)

Adjustment and facing difficulty bravely
The nurses in this study gradually adjusted their emotional outlook and faced their responsibilities with a more positive attitude. In facing PVV, they used their personal experiences to develop more-appropriate patterns of response.

Strategies for Surviving Further Violence
External support The nurses in this study expressed that when violence occurs suddenly, they were unable to deal with families who were alone, in a state of heightened emotion, and verbally or physically violent. Immediate assistance from external sources of support effectively helped halt violent incidents and minimize the damage.
Hopefully, external support will come quickly to the scene to assist when we (nurses) perceive the threat of violence. If it is a communication problem between two parties [nurses/patients/families], a third party can intervene and ease the atmosphere. (Nurse Iris)

Caring for nurses subjected to violence
The nurses in this study identified employee assistance programs as a crucial source of support.
Mutual care between hospital supervisors and colleagues makes me feel that the whole team is cohesive. I really need the assistance of hospital supervisors during follow-up procedures. (Nurse Jason)

Prevention and training
Nurses reported that WPV prevention training was not available to them and that these training programs are important to effectively reducing PVV.
…given the temporal immediacy when dealing with violent incidents, violence training programs are really important for us. I believe that these programs can increase my awareness of workplace violence and how I should deal with related situations. Simulated situations and case studies can also improve my problem-solving ability and emergency management. (Nurse Gail)

Discussion
The findings of this study provide insights into the phenomenon of PVV and validate the claim from prior studies that PVV is an endemic problem widely affecting ICUs. The participants reported that PVV resulted from mutual misunderstandings, unrealistic expectations, delays in providing assistance or information, and verbal expressions of dissatisfaction. The findings regarding the causes of violence are consistent with those of Bingöl and İnce (2021), who found that patients and their families may initiate violence in response to an unexpected disease prognosis, insufficient understanding of treatment information, or unmet treatment needs (Bingöl & İnce, 2021). Patients and their families transfer their feelings of dissatisfaction to nurses, resulting in verbal aggression and even physical violence (Niu et al., 2018;Rayan et al., 2019). Findings from this study indicate a cognitive gap between nurses and patients/visitors regarding patient prognosis and Violence in Intensive Care Units VOL. 31, NO. 4, AUGUST 2023 treatment-related expectations and demands. This gap serves as a trigger for violence. In an earlier study, 57.1% of physical PVV was found to be associated with the cognitive gap between health professionals and patients (Liu et al., 2015).
This study highlights the importance of recognizing verbal violence such as threatening language in the workplace as significantly related to patient/visitor fears, anxiety, and helplessness (Shi et al., 2020;Zhan et al., 2019) and as a potential risk factor for subsequent physical violence. The nurses in this study who had encountered violence became more fearful as a result, fearing they would shrink back from similar violent encounters in the future and that they might continuously brood about the incident. These fears may influence career plans and result in long-term mental distress (Karatuna et al., 2020;Shi et al., 2020). Furthermore, this study found that the nurses were not familiar with the concept of emotional adjustment, which may relate to Chinese cultural norms regarding emotional responses.
The nurses in this study expressed that they were being treated unfairly or unreasonably. Several distinct consequences of this were associated with physical, psychological, emotional, and work functioning dimensions as well as changes in communications and relationships with patients/visitors. This finding is consistent with previous studies (Newman et al., 2021;Zhan et al., 2019). The nurses' responses to violent incidents included recurring disturbing memories and hypervigilance when working, indicating nurses feared being attacked again. This is consistent with an earlier study, which found that nearly all nurses (95.5%) experienced flashbacks after PVV incidents (Al-Sahlawi et al., 2003). Furthermore, the findings of this study are also in agreement with studies showing psychological distress to be the most commonly reported consequence of WPV (Newman et al., 2021;Rayan et al., 2019;Shi et al., 2020). In prior studies, 36% and 14%-17% of nurses were found to display clinical levels of general distress and symptoms of posttraumatic stress disorder, respectively, after a severe incident of physical violence in their ward (Lee et al., 2015;Newman et al., 2021;Rayan et al., 2019). Specific patient characteristics have been shown to increase the risk of ICU nurses experiencing PVV. Violent behavior is also related to the underlying physical health and mental health status of the patient. Critically ill patients in ICUs are significantly different in terms of disease severity and other health problems than patients in general wards . Specific examples of these differences mentioned by nurses in this study were delirium and pain. Families were often unable to cope with sudden and significant changes in patient health, resulting in their strong emotional reactions. Families were not psychologically prepared for rapid deteriorations in a patient's condition and had no coping or release mechanisms for their strong and fluctuating emotions. They would frequently deny the reality of the changes and resist adjusting their expectations and feelings, resulting in grief and anger and, often, being overwhelmed by grief. In particular, when patients became critically ill or died, their families would not accept it because of their excessive sadness, which led to irrational emotional reactions and physical violence. Paranoia has also been identified as a common and serious problem among patients in the ICU , with paranoia-related PVV posing a significant risk to the physical and mental health of nurses, regardless of the patient's state of consciousness.
This study also found other reasons for violence against nurses, including poor and insufficient communication, lack of friendliness or politeness, and impatience arising from patients and their relatives. The psychological state of families increases the probability of angry, anxious, and irritable outbursts and of being excessively cautious about any changes in the patient's disease or related treatments. The psychological status of patients and families influences their behaviors and may contribute to less effective communications between nurses and patients/families (Liu et al., 2015). When their requirements are not met during treatment, conflicts arise easily. This is supported by a prior finding that "patients did not meet all the requirements for treatment" (57.9%) as a major factor underlying WPV (Liu et al., 2015).
This study also confirmed poor nurse-patient relationships was an important underlying factor of PVV in ICUs, which further reduces the limited time available to explain disease or discomfort (Döndü & Yasemin, 2021;Llor-Esteban et al., 2017;Somani et al., 2021). Particularly, this may lead to inadequate dealing with violence at work because of incomplete risk assessments, which in turn may increase the risk of new violence (Llor-Esteban et al., 2017). In light of this, a concerted effort to improve the communication skills of nurses has been suggested (Johnsen et al., 2020;Liu et al., 2015;Phillips, 2016).
This study also confirmed that nurses who experience PVV feel disrespected yet are expected to maintain professional care and patient safety, which results in obvious dilemmas. In this study, PVV experiences were found to be associated with poor job satisfaction; reduced professional enthusiasm, job commitment, and performance; and loss of confidence, which echoes the findings of other studies (de Looff et al., 2018;Gu et al., 2022;Salyers et al., 2017).
In an earlier study, only 16% of healthcare professionals working in ICUs were found to have received training in aggression management (Hahn et al., 2013). The lack of violence-related research in ICU settings has negatively influenced the ability of hospitals and wards to build and maintain WPV prevention and training programs, with clear implications for nurses. Therefore, other more-effective techniques for dealing with and deescalating violence have been suggested (Döndü & Yasemin, 2021;Papadopoulos et al., 2012;Somani et al., 2021).

Limitations
This study is affected by several limitations. Although the depth and richness of the information provided in this qualitative study is adequate for exploratory purposes, the sample size was small. Thus, the generalization of the findings to broader contexts and further investigations of causality are difficult and may be addressed in future studies.

Conclusions
The findings of this study support that PVV is a significant problem for nurses in ICUs and that verbal violence is the most prevalent form of violence experienced. This study used qualitative data to articulate a framework for violence prevention in ICUs that is based on the lived experiences of nurses who had experienced PVV. These findings and the framework may be used as a guide to build the foundations for ongoing efforts to reduce and prevent violence in healthcare settings. The body of information in the literature is sufficient to now move from defining and describing PVV in ICUs to constructing and implementing related training programs.
In this study, some of the implications for nursing managers arising from the research findings were considered. Interventions, training programs, and management actions should be employed to ensure that psychological and mental support is not limited to ICU nurses directly affected by PVV but rather extended to all who witness violent events.
Furthermore, the study findings provide an important avenue for clinical practice. Routine confusion and delirium assessments should be made to identify patients with ICU delirium in ICUs to implement related preventive measures and further reduce the risk of violence.