Violence and Aggression in Operating Room

Introduction: Operating room (OR) is a high-tense working environment from one hand but it is also a place where team work is needed and expected to be done. Good working relationships in operating room field are necessary in order safety and high quality of healthcare to be the standard of everyday practice. Verbal abuse is a common phenomenon that takes place between healthcare professionals and more often between physicians and nurses. Aim of the study: To determine the problem of verbal abuse in Greek Operating Rooms and to investigate its causative factors. Methodology: The study was conducted as a descriptive correlational design. The research population was composed of the nurses working in ORs of hospitals in Greece. 65 OR Registered nurses answered the questionnaire which was sent to them in electronic way (link). Results: The mean age of the nurses was 41.4 ± 6.83 years .OR nurses who participated in the research have been working for a mean period of 12.7 ± 7.82 years. The most of the nurses (92.4%) stated that they have been experienced verbal abuse in the workplace. The participants in 56.9% said they have taken some kind of formal training in communication skills. 1/3 of the sample (35.4%) who took part in this study were victims of verbal violence more than once a year and also roughly the same percentage (27.7%) believes that nurses confronted with verbal violence more than once weekly. The relationship between abuser and victim as a large percentage of 23.1% specify was a "physician". OR nurses experience frequent and severe levels of verbal abuse. Conclusion: This study’s findings indicated that the most common emotional reactions toward verbal abuse reported by OR nurses was anger followed by disgust, sadness and shock. It is imperative that OR nurses obtain special training in the recognition, management and development of strategies to deal with verbal abuse.


Introduction
Violence in healthcare is any aggressive behavior aimed at inflicting harm or discomfort on its victims (Felton, 1997). Operating room (OR) is a high-tense working environment from one hand but it is also a place where team work is needed and expected to be done. Good working relationships in operating room field are necessary in order safety and high quality of healthcare to be the standard of everyday practice. Verbal abuse is a common phenomenon that takes place between healthcare professionals and more often between physicians and nurses. In a survey conducted in 2004, 79% of physician executives indicated that problems with physician behavior occurred within their organizations more than 3-5 times a year. Verbal abuse may lead to negative personal feelings and relationships between physicians and nurses, and it negatively affects patient care. Disruptive behavior can undermine morale, increase turnover, decrease efficiency, consume resources, and threaten patient safety is reported by Leape and Fromson, [1] and Pfifferling [2].
This study was conducted in order to determine the problem of verbal abuse in Greek Operating Rooms and to investigate its causative factors. Not only there is little recognition of the problem of verbal abuse in Greek OR's but there isn't any process to report attacks and policies to protect employees-victims so this research aimed to deal with the problem.

Methodology Design and ethical considerations
The study was conducted as a descriptive correlational design and data was collected with a questionnaire form. Ethical approval was obtained from the Institutional Ethics Committee. The study was conducted after obtaining written consent from hospitals, and informed consent from the nurses.

Settings and participants
The research population was composed of the nurses working in ORs of hospitals in Greece. 65 OR nurses answered the questionnaire which was sent to them in electronic way (link). Inclusion criteria were that OR nurses had to be members of Greek Operation Room Nurses Association. Operating Room nurses that took part in the study have been working in public hospitals in Greece as circulator or scrub nurses. OR Nurses were reassured that the data would be kept confidential.

Questionnaire
Participants completed an adapted questionnaire, incorporating the Verbal Abuse Scale and the Verbal Abuse Survey and demographic questions developed by the researchers. Cox's [3] Verbal Abuse Survey and the Verbal Abuse Scale by Manderino and Berkey [4].
Specifically, types of verbal aggression, the frequency and stressfulness of each type, emotional reaction to verbal aggression, cognitive appraisal of verbally aggressive encounters, and similarity and effectiveness of coping behaviors were explored.
The subscale of frequency and severity of verbal abuse comprised 10 forms of verbal abuse, to which respondents were invited to rate how often and how severe these forms were in their experience, on a scale of 1 (never experienced/not at all severe) to 5 (experienced every day/ extremely severe).
The subscale of emotional reactions to verbal abuse comprised 13 emotions in response to verbal abuse. These emotions were rated on a 5-point Likert scale that ranged from 0 to 6 with zero indicating not at all to mild feeling and 5 indicating very strong feeling. The subscale indicating behaviors used by verbally abused nurses to deal with the abuse were rated on a 5-point Likert scale that ranged from 1 to 5 with zero indicating that they never used that behavior and 5 indicating that they used the behaviors very frequently. Items that scored three or more were considered relatively frequently used behaviors.
Eighteen emotional responses were listed and subjects were asked to rate the degree to which they reacted emotionally when they experienced verbal abuse on a 0-5 scale (1=Not at all, 2=Mild feeling, 3=Moderate feeling, 4=Strong feeling, 5=Very strong feeling).

Data analysis
Statistical analyses were undertaken using Statistical Package for the Social Sciences for Windows Version 19.0. Data were evaluated by frequency and descriptive statistics. Cronbach's a yielded a high level of internal consistency 0.9 for the total instrument. Descriptive statistics were calculated to summarize the demographic data (t-test). A two sided P<0.05 was considered statistically significant.

Results
The mean age of the nurses was 41.4 ± 6.83 years .OR nurses who participated in the research have been working for a mean period of 12.7 ± 7.82 years. The most of the nurses (92.4%) stated that they have been experienced verbal abuse in the workplace.
The participants in 56.9% said they have taken some kind of formal training in communication skills. 1/3 of the sample (35.4%) who took part in this study were victims of verbal violence more than once a year and also roughly the same percentage (27.7%) believes that nurses were verbally abused more than once weekly. The relationship between abuser and victim as 23.1% of the sample specify it was a "physician". 66.7% of the participants believed that the abuser knew the outcome of his/her action. The 93.9% of the victims claimed that the episode occurred in front of others and 34.8% of them stated that this caused them great anxiety. 84.8% of the victims also consider that incidents of verbal violence cause increased errors in everyday practice in Operating Rooms. Table 1 describes how frequently abuse had occurred (0=never, 1=1-6 times this year, 2=once a month, 3=2-3 times per month, 4=once a week, 5=several times a week, 6=everyday) as well as how stressful were the incidents (0=not at all, 1=very slightly stressful, 2=mildly stressful, 3=moderately stressful, 4=stressful, 5=very stressful, 6=extremely stressful).    Table 2: Emotional reactions to verbal abuse. Table 3 provides mean scores attributed to the behaviors used by verbally abused nurses to deal with abuse. Findings indicate that the behaviors used most by OR nurses were: I clarify any misunderstanding (M=3.37, SD=1.46), I discuss the situation directly with the physician (M=3.25, SD=1.51), I get busy with positive activities to reduce my tension (M=3.12, SD=1.68), I speak to myself with reassuring way (M=3.03, SD=1.66). The behaviors used the least by Jordanian nurses were I discuss the situation directly with the physician (M=1.64, SD=0.83), and I clarify any misunderstanding the physician may have (M=1.05, SD=1.14).

Behaviors used most by OR nurses
Mean SD

Discussion
This study indicated that OR nurses experienced frequent and severe levels of verbal abuse. These results are consistent with previous studies [4][5][6][7][8][9]. In this study, judging and criticizing, accusing and blaming, and Verbal abuse (VA) disguised as a joke were the most frequent and most severe types of verbal abuse encountered by OR nurses.
This study has identified physicians to be one of the main sources of verbal abuse in ORs something that matches with other researchers' findings [10][11][12].
In 1992 Evans' research stated that physicians use verbal abuse to gain power over others and to maintain their prestige or it may reflect a communication style that frequently yields favorable results for the physicians or it might be a reaction to self-frustration or stress that Operating Room creates.
This study's findings indicated that the most common emotional reactions toward verbal abuse reported by OR nurses was anger followed by disgust, sadness and shock. Anger has been identified as the strongest frequent emotion associated with verbal abuse and many researchers have found [7,8,13,14]. Findings also indicated that the behaviors used most by OR nurses to deal with verbal abuse were clarifying any misunderstanding, discussing the situation directly with the physician, getting busy with positive activities to reduce my tension. This coincide with the findings of Manderino and Berkey [4] who report that nurses in their study engaged in more positive activities to deal with verbal abuse.
Accurate reporting of any episode of violence is essential in order to interrupt the cycle of future incidents. The findings of this study highlight the need for protocols development for reporting and dealing with verbal abuse. It is imperative that OR nurses obtain special training in the recognition, management and development of strategies to deal with verbal abuse. Nursing management should provide ways in order strategic mechanisms will be provided to nursing personnel in order to deal with abuse more effectively without self-defeating behaviors.