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Bachelor in science (Nursing) (BSC Cur)

Research ProposalSenior Sophister 2010-2011

Title:

A quantitative descriptive study exploring:

The incidence of violence and aggression towards

student nurses in teaching hospitals.



1

Table of contents

Chapter one Page number:

1.1 Introduction 41.2 Alcohol related incidents 61.3 Staff training 71.4 Effects of violence and aggression 91.5 Conclusion 101.6 Research question 101.7 Aims and objectives 10

Chapter two2.1 Introduction 122.2 Research design 122.3 Population & sample 132.4 Data collection 152.5 Validity and Reliability 16

2.6 Pilot study 17

2.7 Data analysis 18

2.8 Ethical considerations 19

Chapter three

3.1 Proposed outcome of study 21

3.2 Recommendations 21

3.3 Dissemination of findings 21

Appendices.



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I hereby declare that this Research Proposal is entirely my own work

and has not been submitted as an exercise for assessment at this or any

other University.

Signed...............

Print...................

Date....................



3

Abstract.

The subject of aggression and violence towards nurses within a clinical

setting has been researched for many years in different parts of the

world. Despite the research that has already been conducted

highlighting the on-going and worsening issue of violent and aggressive

acts by patients towards nurses, there is little research conducted using

student nurses who are the nurses of tomorrow as the sample

(Hinchberger 2009).

The literature that was examined for the proposal highlights the factorsthat facilitate these acts of violence and aggression to occur. It also

highlights the effects that these incidents have on the person who

experiences it in the workplace; however few researchers have

investigated the problem as it exists in Irish hospitals, nor used student

nurses as the sample population. The literature has highlighted to the

author that aggression and violence in the workplace is an ongoing

problem that is continuously overlooked as being anything of great

significance. The reasoning behind this study is to investigate the

factors that allow these acts to occur and to establish whether it is

having a damaging effect on Irish student nurses.

A descriptive quantitative study will be conducted using a questionnaire

adapted from Rose (1997). An estimated 200 nursing students from 2

teaching hospitals in Ireland will be selected as the sample population.

Inclusion and exclusion criteria needs will be established before the

questionnaires are sent out. A pilot study will first be conducted using

10% of the sample population to test the reliability and validity of the

questionnaire. The author will seek the necessary ethical approval

before conducting the study. It is anticipated that the findings of this

study will highlight the worsening issue of violent and aggressive acts

towards student nurses and will hopefully contribute to training coursesbeing implemented within the clinical and academic setting.



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Chapter one

The research problem

1.1 IntroductionThere are numerous definitions of violence (Saines 1999) defines

violence as any episode which puts a health care worker at risk and it

includes verbal abuse, threatening behaviour or assault by a patient.

Aggression is described as animosity or hostility shown towards another

person as a response to frustration or opposition (Burr et al. 1998).

Violence and aggression in the health care setting has been ever more

acknowledged as a significant problem (Wyke 1994). The majority of

nurses working within a health care setting are female and are 3 times

more likely to encounter violence than any other professional group

(NIOSH 2006). The results of workplace violence towards nurses can

have distressing emotional effects such as feelings of anger, sadness,

fear and depression (Grenyer et al. 2004). Workplace violence has been

linked to the increase of post-traumatic stress disorder, the need for

sick leave and reduced levels of work performance and job satisfaction

(Jackson et al. 2002). Despite the appreciation of these side effects,

many nurses accept aggressive and violent acts as part of the job.

Lanza (1992) proposes that by tolerating this workplace violence as a

normal event many nurses are desensitizing themselves to working in

dangerous and unstable situations.

The topic of violence and aggression in the workplace has been widely

researched throughout the years and it is noted that the research on

violence on nurses generally excludes student nurses in the sampling

population (Hinchberger 2009). Published literature has demonstrated

the need to acknowledge this problem in Ireland as one studys findings

showed that 81-89% of respondents in a sample had been exposed and



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less than one third of heath care staff reported having training in the

management of aggression and violence (Ryan 2006).

This author has chosen to conduct a research proposal on this topic as

they have had direct experience of violence and aggression within the

hospital as a student nurse. A review of the literature found that

student nurses are frequent targets of aggression and consider

themselves as powerless in dealing with it (Beech & Leather 2002). The

author believes a study is required to investigate the reasons why

violence and aggression occur and what are the effects on the person.

The author has conducted a search of relevant literature regarding the

issue and with rigorous searches through the databases could find only

few studies conducted in an Irish setting, therefore this author believes

it may be useful add more research to what is already known about this

topic in Ireland. The author used the following databases in the search:

CINAHL, ProQuest and internurse, from this search 20 articles were

located that were relevant to the topic, manually 3 articles were located

within the Trinity College library and 2 anecdotal pieces were considered

relevant and included. There were no limitations to the search of

relevant literature as the researcher wanted to gain an idea of how

much the topic had already been researched.



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1.2 Alcohol related incidents.

Alcohol is a depressant psychoactive drug which has immense effects on

the individuals who consume it (Plant et al.2002). The side effects of

alcohol include reduced fear and over reactions, it diminishes the

individuals ability to make rational decisions (Graham et al.2003). A

distinctive theme evident throughout many of the articles exploring

violence and aggression is alcohol. A study by Jenkins et al(1998)

found that alcohol was deemed the most likely triggering factor of

abuse by 98% of respondents. Similarly a study by Morgan & Steedman

(1985) also found that alcohol was documented as a connected factor in

71 out of 102 violent incidents. A study by Crilly et al(2003) waspiloted to establish the reason and occurrence of violence towards

nurses. A descriptive longitudinal cohort design study was carried out in

2 public emergency departments in Australia. All registered nurses who

had patient contact were invited to take part in the study. The final

response rate was 66% with 108 participants. The results of the 5

month study showed that 70% of nurses reported violent incidents

during this period. A total of 53% reported being verbally abused and

26% experienced episodes of both physical and verbal abuse. The

nurses within the study described that they believed alcohol had a giant

role to play in these incidents, however without any solid evidence to

prove that alcohol was the causative factor and the small sample size

they strength of the article was greatly reduced.

Schnieden & Marren-Bell (1995) conducted a study to review the types,

possible factors and commonness of violence in the workplace. Nurses

from the Royal College of nursing where randomly selected and

questionnaires were sent to those selected. Demographic details and

frequencies of verbal and physical violence were requested. The

response rate was 196 out of 300 completed the questionnaire (65%);

it was found that 22.9% of nurses said that alcohol was maybe related

to physical violence and 73.4 said it was definitely related. 75% ofrespondents concluded that alcohol was absolutely associated to verbal



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abuse and 21.4% said maybe. Due to lack of under reporting of

physical and violent incidents, it is difficult to prove whether alcohol was

the causative factor as these findings are based on opinion and they do

not support the suggestion alcohol is related to abuse.

1.3 Staff trainingStaff training or lack of staff training is a theme that was evident

throughout the literature. The literature highlights the differences in the

number of nurses who were trained in managing violence and

aggression and those who were not. Shah & De (1998) determined thatif nurses are mindful of potential triggers of aggression and violence it

may result in healthier management of the psychological effects of

workplace abuse. Suitable training in the management of aggression

and violence is the first step nurses can take to protect themselves as

Whittingtion (1997) found that unsuccessful training was a main factor

in the incidence of workplace violence. A study by Atawneh et al(2003)

was conducted to examine the rates, frequency and severity of violence

in a general hospital in Kuwait. The tools used for the study was a 12

item frequency weighted questionnaire. The sample population

comprised of all the nurses working within the emergency department

of the hospital. With a 94% response rate the researchers from the data

collection that 86% reported having experienced violent incidents that

included both verbal and physical. Only 15% of the sample had any

type of training to cope with aggressive behaviour and 44% believed a

training programme would be valuable. Although the small sample size

greatly reduces the strength of the study, these findings are supported

by Schnieden & Marren-Bells (1995) study on workplace violence in an

English hospital.

The study comprised of a questionnaire survey on 196 nurses and found

that over half of the nurses had received no formal training in managingviolent and aggressive patients and only 18.4 had information on



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aggression and violence on an induction course and 89.1% had never

received an update. Deans (2004) conducted a study to examine the

efficiency of a once off training programme in managing aggressive and

violent situations. The research design method involved using a non-

experimental one group pre-test, post-test on a sample of 24 nurses.

Deans (2004) proposes that an effective training programme can help

nurses reduce the incidents of violence and aggression by 50%. The

results from the study found that the occurrence of aggressive

situations experienced by nurses was reduced from 11.3% to 3.4%

within 3 months. A rise in confidence to deal with potential aggressive

situations from 4% to 13% was also noted. The sample size does

reduce the strength of the survey however the results show a training

programme does work. These findings are supported by Beech &

Leathers (2003) study on the prevention and management of

aggression for student nurses. The purpose of the study was to

measure outcomes of the group of students in the unit and gain more

awareness about more general issues in evaluating training

effectiveness. The researchers state that student nurses are common

targets of aggression but are worryingly less likely to receive specific

training. A repeated measures longitudinal design was used to gather

data from 3 groups of 20 students over an eight month period. A

questionnaire was administered twice before the unit, at its conclusion

and approximately 2 months afterwards. They found that statistically

substantial changes were demonstrated in a number of areas including

number of risk factors identified after the 3 day learning unit.

Beech & Leather (2003) state that it is possible to provide training that

produces desirable, statistically demonstrable and durable changes in

knowledge. Deans (2004) states that continuous training is key in

providing nurses with the competence and confidence in dealing with

aggressive situations. As todays student nurses will be the working

nurses of tomorrow, training programmes should be a core part of their

overall nursing training.


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1.4 Effects of violence and aggression

Acts of violence and aggressive behaviour towards nurses can have

devastating effects on their mental health. There have been many

studies that have proven the adverse psychological effects it has on a

nurse such as, insomnia, agro phobia and depression (Income data

service study 1990). Schnieden (1993) also found that perceived

vulnerability to further episodes may lead the nurse to take sick leave,

cause poor staff morale and a higher than necessary staff turnover.

Atawneh et al(2003) directed a questionnaire survey to measure the

effects of violence. The researchers found that 96% of nurses who had

experienced violence at work suffered from one or more after effects

that included: flashbacks, depression, sleeplessness, fearfulness and

time off. It was revealed that 59% suffered all 5 effects. Chapman

(2009) found that many nurses who experienced workplace violence

questioned their capability as a nurse because they felt overcome and

helpless. These findings are reinforced by a questionnaire based survey

conducted by Farrell et al(2006). The study focused on nurses working

in a hospital in Tasmania and those who had left a position. The

researchers found that 11% of the sample said they had left a position

in their career due to aggressive incidents, 24% of the sample said they

had thought about leaving the position in the last 4 weeks and 2% said

they had left the profession altogether because they were unable to

cope with the effects of workplace violence.

Maslach & Jacksons (1986) theory on burnout suggests that patients

being cared for by nurses working in high levels of stress may not

receive the best quality of care. Chapman (2009) found that nurses who

had been victims of workplace violence had become hesitant to look

after aggressive patients. Maslach & Jackson (1986) also established

that an individual suffering from burnout may begin to suffer from the 3

common symptoms of burnout: exhaustion, reduced job satisfaction

and desensitisation of the client. It is evident from the literature that

workplace violence has devastating effects on the nurse who



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experiences it with burnout being one of the major implications of

workplace violence and aggression.

1.5 Conclusion

Alcohol has been implicated as being the main causative factor in

workplace aggression. From studying the literature there was found to

be a general consensus that alcohol did indeed play the biggest role,

however due underreporting of alcohol related violent incidents and the

majority of findings being based on opinion of the participants, the

findings lacked credibility. Fern (2005) stated that findings from a studyconducted by Jenkins et al(1998) were no more than assumption due

to the lack of solid data that prove nurses were experiencing workplace

violence by individuals who were under the influence. It is important to

note however that nurses working in areas such as the accident and

emergency department are more likely to be caring for individuals who

are under the influence of alcohol and substance abuse, so it is the

researchers aim to highlight the potential problems that can arise from

alcohol.

Lack of staff training is having a direct impact on the nurses being able

to manage violent and aggressive patients in the health care setting.

The literature has shown that training programmes in the management

of aggression and violence would be valuable, as Deans (2004) study

on the usefulness of a once off training programme has proved they do

work. Beech & Leather (2004) stated that student nurses are frequent

targets of aggression as they are considered powerless, however they

are less likely to receive any training in managing violent and

aggressive patients which leaves them vulnerable as not only students

but when they qualify to workplace violence.

The effects of violence and aggression were shown throughout the

literature to have horrendous effects on the individual who experiences

it. Maslach & Jackson (1986) suggested that burnout has serious



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consequences on the individual which can eventually lead to exiting the

profession. Student nurses who are frequent targets of aggressive

behaviour may begin to suffer from symptoms of burnout before they

have qualified. Aggression and violence towards student nurses must be

highlighted because as our government cuts health expenditure and

decreased staffing levels are more prevalent on the wards due to the

current economic climate, the hospital setting is a very stressful and

hard place to be for staff, students and patients alike. Student nurses

may find themselves experiencing the backlash of angry patients who

are fed up with the health system at present and feel they are not

receiving the quality of care they should be getting.

1.6 Research Question

The proposed research question is:

What is the incidence of violence and aggression by patients towards

student nurses and are they able to deal with it effectively?

1.7 Aim & objectives

Aim: To determine the incidence of violent and aggressive acts towards

students and to investigate whether or not they can effectively deal

with it.

Objectives

(1) To determine the frequency of violence and aggression towardsstudent nurses.

(2) To investigate the factors that facilitates violence andaggressive acts to occur.

(3) To determine if student nurses can effectively cope with andwhat impact these violent incidences had on them.

(4) To make recommendations for clinical practise and furtherresearch.



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Chapter 2: Methodology

2.1 Introduction

In this chapter the researcher must select the most suitable

methodology to answer the research question. It is anticipated that the

chosen methodology will accomplish the aims and objectives of the

study.

2.2 Research design

Research methods can be divided into two groups: qualitative and

quantitative. The purpose of a research design is to describe how, when

and where data is to be analysed for the research issue (Parahoo 2006).

According to Watson et al(2008) quantitative research is based on

numerical data or quantities and is concerned with the detection of

general laws. It tends to focus on control of events and claims to beobjective (Punch 2005). It produces empirical data which is important

for evidence based practise (Parahoo 2006). Parahoo (2006) states that

the findings of quantitative research should be generalizable.

Alternatively qualitative research methods gather verbal or

observational data; it focuses on peoples experiences and

understanding these experiences by taking on and insiders perspective.

In doing so, researchers acknowledge and use their subjectivity

(Morgan & Drury 2003). A qualitative method will not be used for this

study as the researcher wishes to obtain factual empirical data on the

incidence of violence and aggressive acts towards student nurses,

therefore a quantitative method will be used at the data collected can

be statistically analysed. The research design chosen to produce data on

this topic is a descriptive quantitative study that will use a structured

questionnaire. This method of gathering data is advantageous in

reducing the risk of researcher bias as the researcher will have very



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little dealings with the participants in the study (Parahoo 2006). The

researcher hopes to gather new information on the chosen topic as

there is little research done on the incidence of violence and aggression

by patients towards student nurses in Ireland. It is anticipated that the

data collected in the study will be utilised in nursing education and

preparation for clinical placements for future practise.

2.3 Population and sample

2.3.1 Population

Polit & Beck (2008) describe a population as being all the individuals or

objects with common, defining characteristics from which data can be

collected. The target population is a group of subjects that fit the

research criteria (LoBiondo-Wood & Haber 1998). The planned

population for this research proposal are student nurses who have

completed their accident and emergency placement and are in their

final year of general nursing. A sample of this population will be

selected as due to time constraints it is not achievable to study every

student nurse in Ireland. A sample is defined as a subset of the target

population (Parahoo 2006). Students from 2 major teaching hospitals in

Dublin doing the 4 year degree programme in nursing will be selected

as the sample population and must meet the sampling criteria.

Inclusion criteria

Participants must have completed their accident and emergencyplacement.

Participants must be in their final year of nursing. Participants must be over 18years of age. Participants must be skilled in reading and speaking English Participants must be in the General class of the Nursing degree

programme.

Exclusion criteria



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Participants not in the general setting Participants not meeting the above criteria.

From this inclusion and exclusion criteria, a sample can be selected.

2.3.2 Sample selection and size

The sample is selected so it can provide the researcher with data that is

representative of the whole population so that inferences of the

population can be made (Polit & Beck 2008). A letter of invite (Appendix

1) for the proposed study will be sent to the Director of the nursing

degree programme to gain consent and to gather the samples who

meet the criteria. Letters will also be sent to the ethics committee of

both hospitals for approval (Appendix 2)

The type of sample chosen for this study is non-probability sampling in

the form of purposive sampling. Non-probability samples are made up

of units whose possibility of selection is not known in advance (Parahoo

2006). Purposive sampling involves the researcher deliberately choosingwho to include in the study with the impression that those selected can

provide them with the necessary data (Parahoo 2006). Small samples in

quantitative research are unlikely to produce results of significance

(Parahoo 2006). Large sample sizes are advised in quantitative studies

as the more representative it is likely to be to the population (Polit &

Beck 2008). In order to try increase the generalizability of the study, 2

major teaching hospitals have been selected. Often with questionnaires

the response rate can be low so a larger sample is required to increase

the strength of the study, however due to time constraints and funding

issues no more than 2 hospitals will be selected. All students who have

completed the A&E placement and are in their 4th year of study will be

included for the study. An estimated 200 students will be selected as

the sample population from the 2 major teaching hospitals.



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2.4 Data Collection

Burns and Grove (2003) state that the data collection procedure is the

identification of subjects, and the precise systematic gathering of data

relevant to the research purpose. The data collection methods are

physiological, observational, interviews, questionnaires and records

(LoBiondo-Wood 2002). The chosen method for collecting data for this

study is a structured questionnaire (Appendix 3). Questionnaires are the

most usual method of data collection in social and health research

(Parahoo 2006). They are most appropriate for producing data on

prevalence, trends, incidence and patterns (Watson et al. 2008) which

is the most suitable tool to use to collect data on the research question.Questionnaires are a cheap and quick way of gathering large amounts

of data (Parahoo 1997). Questionnaires can potentially guarantee

anonymity and this may encourage some respondents to reveal details

of behaviour which they may not do in interviews, making them more

reliable than other methods (Watson et al. 2008). Disadvantages in

using a questionnaire include misinterpretation of a question or the

sample not understanding the question which will make the answer

useless. If the questionnaire is too long many people will be inpatient

with filling it out and not complete the questionnaire which is why it is

important to keep it simple and concise.

The data for this proposal will be collected using a questionnaire

adapted from Roses (1997) questionnaire survey on violence and

aggression towards nursing staff in the accident and emergency

department. The researcher used this questionnaire and added in 2

open ended questions so the participants could have the opportunity to

give more detail about certain points. Developing a questionnaire is

systematic, time consuming and painstaking (Watson et al. 2008) and

due to time constraints the researcher has chosen this adapted version

as appropriate to the study. A letter requesting permission to use and

adapt the questionnaire will be sent to the original creator of the tool(Appendix 4). The questionnaire consists of 11 closed ended questions



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with 2 open ended questions to let participants answer in their own

words and gain greater insight into the research problem (Burns &

Grove 2007). The questions will be short, concise and comprehensive

which will hopefully increase the response rate, the questionnaire

should take no longer than 10 minutes to complete. A cover letter

(Appendix 5) will be included with the questionnaire describing what the

research is about; whose research it is and what potential contribution

it can make. Assurance of confidentially will be included in the letter

(Watson et al. 2008). A stamped addressed envelope will also be

included to try and enrich the response rate. A contact address for the

researcher will be included should the participants have any queries. A

reminder letter will be issued to all participant two weeks after the first

questionnaire was sent out to encourage those who have not finished it

to do so and to thank those who did (Appendix 6).

2.5 Validity and Reliability

There are two key concepts that concern the value of research: validity

and reliability (Gerrish & Lacey 2006). For the questionnaire to be of

use to the researcher it must produce valid and reliable data (Parahoo

2006). Burns and Grove (2003) state the validity of an instrument is a

determination of how well the instrument reflects the abstract concept

being examined. There are three different types of validity: content

validity, predictive validity and construct validity (Burns & Grove 2003).

Content validity is the degree to which the items in an instrument

adequately represent the universe of content for the concept being

measured (Polit & Beck 2004). The questionnaire will be sent to a group

of professionals who have the expert experience and knowledge in the

area of aggression and violence within an acute setting, so they can

analyse the tool and make suggestions to better improve it if necessary.

The group will consist of nurses with research backgrounds, clinical

nurse managers and college lecturers. Face validity is another method

in measuring the validity of a tool. It confirms that a measuring



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instrument looks as though it is measuring what it means to measure

(Polit & Beck 2004). Face validity will be assessed by friends and family

who will study the questions to ensure they are concise and easy to

complete (Polit & Beck 2004).

2.5.1 Reliability

Polit & Beck (2004) describe reliability as being the degree of

consistency or dependability with which an instrument measures on

attribute. Reliability is concerned with the dependability of results from

the questionnaire (Burns & Grove 2007). The reliability of the

questionnaire will be tested using the test-re-test reliability method,

which involves administering the same questionnaire to the same

people after a certain period of time. The reliability of the questionnaire

can be estimated by examining the consistency of responses between

the two sets of data (Gerrish & Lacey 2006). Reliability is measured by

numbers called coefficients. If the same result is achieved both times

the questionnaire is administered then the reliability coefficient will be

1.00. Burns & Grove (2003) state that reliability coefficients that have a

score higher than 0.70 are deemed acceptable. The researcher will aim

to achieve a reliability score of 0.70 for the study.

2.6 Pilot study

A pilot study of the questionnaire will be performed before data

collection commences. (Watson et al. 2008). A pilot study is a smaller

version or trial run devised to test the methods to be used in a larger

more rigorous study (Polit & Beck 2004). According to Gerrish & Lacey

(2006) a pilot study will tell reviewers what steps will be taken to

ensure that the proposed methods are workable, are acceptable to

subjects and manageable. The pilot study will allow the researcher to

determine the clarity of the questionnaire, the length of time taken to

complete it and to see if the questionnaire is too extensive (Polit & Beck

2004). The pilot study will be conducted in the same method to theproposed study using approximately 10% of the target sample. Those



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who are selected for the pilot study will not be included in the main

study. The researcher will send a letter of approval to the Director of

Nursing in the 2 hospitals. The proposed questionnaire for the main

study will be used in the pilot study. The questionnaires will be analysed

upon completion using the data collection tool and any errors and

alterations to the questionnaire can be made if necessary. The data

analysis method will also be tested. The results from the pilot study will

not be included in the results of the main study.

2.7 Data analysis

Data analysis is possibly the biggest and most important phase of the

research project, once the data has been collected they need to be

organised and assembled in such a way that conclusions can be drawn

from them (Gerrish & Lacey 2006). Data analysis is conducted to

reduce, organise and give meaning to the data (Burns & Grove 2003).

The questionnaires will be pre coded during the data collection stage as

they are useful in linking the data collected on paper and the data

stored on the computer as it contains information about how the

individual variables are to be named, labelled and coded in the chosen

computer package (Gerrish & Lacey 2006). The pre coded

questionnaires will then be entered onto the computer to be analysed.

The analysis will be done using the SPSS (Statistical Package for the

Social Sciences). A statistician will be consulted to analyse the data so

the results can be written up.

2.7.1 Describing quantitative data

When analysing the data, the first approach would be to calculate

summary measures, to describe the location (measure of the middle

value) and the spread (a measure of the dispersion of the values)

(Gerrish & Lacey 2006). In measuring the location the easiest method is

the mode. It is the most common observation. The median is the middle

observation and the data are arranged in order of increasing value



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(Gerrish & Lacey 2006). The mean is simply the sum of all the

observations divided by the number of observations and is the most

useful measure of the central value of the data.

2.8 Ethical considerations

The main ethical issues which should be contemplated before the

research study can be commenced are: consent, confidentially,

beneficence, non-maleficence and justice (Burns & Grove 2007). Ethical

approval from Research Ethics Committee will be obtained before the study

is commenced as well as the letter of invite to the Director of the nursing

degree programme.Informed consent will be obtained by the researcher

by providing full information that is concise on what the research is

about to the proposed participants by including an information letter

with the questionnaires. The participants will be assured of their

confidentially as the questionnaires are not identifiable through names

and all data collected will be held in a secure area. All participants will

be made aware of the benefits of the study, the study aims to

determine the incidence of violence and aggression towards student

nurses, which best serves the interest of those taking part. All data

collected will be stored on a laptop which is password protected and all

raw data will be destroyed after five years. Non maleficence is a term

that is linked with the concept that it is better not to harm the

participants than do them good. All proposed participants will be fullyaware of what the research questionnaire entails and have the right to

withdraw from the study without consequences. To assure justice all

participants will be treated fairly with no individual receiving preferential

treatment (Burns & Grove 2007). As previously mentioned a letter of

approval will be sent to the ethics committee prior to commencement of

the study.



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Chapter 3

3.1 Proposed outcome of study

Upon completion of the research study the author will construct a report

highlighting the findings. When writing up the findings the author will be

vigilant not to project their own bias in this part of the study. It is

anticipated that the instrument used for data collection will produce

findings of importance to the research. The author ensured the

questionnaire used for data collection was concise and simple to

complete to ensure full completion of the questionnaire. The limitationsto this study is the fact that the study was only carried out in two

teaching hospitals in Ireland, which will reduce the chance of

generalising the findings of the study to all teaching hospitals in Ireland.

The author anticipates that the study will highlight the incidences of

violent and aggressive behaviour towards student nurses, and increase

the awareness of potential causes of these acts. It is hoped that the end

results of the study will establish a need for more training and

management techniques of aggressive and violent behaviour within the

clinical setting and tutorial classes.

3.2 Recommendations

The author recommends that a larger study of the same issue should be

conducted in other teaching hospitals throughout Ireland so that the

results can be compared in order to generalise the findings.

3.3 Dissemination of findings.

The findings of the study will be disseminated to the two participating

teaching hospitals and the School of Nursing and Midwifery. The



21

findings of the study will also be discussed with the Director of Nursing

and the head of the School of Nursing and Midwifery if possible in order

to increase the awareness of violent and aggressive acts towards

student nurses. It is anticipated that the study will be published in

nursing journals to give other nurses and students access to the study.

3.4 Time scale.

A clear timetable with objectives to be achieved throughout the study

process demonstrates that the proposal is realistic and achievable

(Cormack,2000).The author anticipates that it will take 16-18 monthsto conduct the proposed study. The proposed time layout is found in

(Appendix 7).

3.5 Budget.

The predicted budget for the study can be found in (Appendix 8)



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Reference List.

Atawneh F.A., Zahid, Al-Sahlawi K.S., Shahid M.D., Al-Farrah M.H.(2003) Violence against nurses in hospitals: prevalence and effects.British Journal of Nursing 12(2)

Beech B., Leather P. (2003) Evaluating a management of aggressionunit for student nurses.Journal of Advanced Nursing 44(6), 603-612.

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Appendix 1

Letter to the Director of Nursing:

1st MarchDear Sir/Madam,

I am currently in my fourth and final year of General Nursing in TrinityCollege Dublin. As part of my final piece of academic work for college Iam required to conduct a research proposal. The study I intend to

undertake is a quantitative study using a structured questionnaire. Myaim is to determine the incidence of violent and aggressive acts towardsstudent nurses and to investigate the factors that facilitate violent actsto occur.The study comprises of 100 General Nursing students from this hospitaland another 100 from a different teaching hospital in Ireland andparticipants are invited to complete a simple questionnaire which willhopefully yield findings of relevance to the study. The inclusion criteriafor the study states that the sample of nursing students must be in their4th year of the general nursing degree and have completed their A&E

placement.

I am writing to request your permission to carry out this study in yourhospital and would appreciate if you could appoint a gate keeper todistribute the questionnaires to those that meet the criteria. If youwould like some more information on the research study please do nothesitate to contact me.

Thank you for taking the time to read this letter.

Yours SincerelyCiara Kelly



26

Appendix 2Letter to the ethics committee:

Ethics committeeXXXX Hospital

1st March

To whom it may concern

I am currently in my fourth and final year of General Nursing in TrinityCollege Dublin. As part of my final piece of academic work for college Iam required to conduct a research proposal. The study I intend to

undertake is a quantitative study using a structured questionnaire. Myaim is to determine the incidence of violent and aggressive acts towardsstudent nurses and to investigate the factors that facilitate violent actsto occur.The study comprises of 100 General Nursing students from this hospitaland another 100 from a different teaching hospital in Ireland andparticipants are invited to complete a simple questionnaire which willhopefully yield findings of relevance to the study. The inclusion criteriafor the study states that the sample of nursing students must be in their4th year of the general nursing degree and have completed their A&E

placement.

A cover letter with each questionnaire will be sent to each participant.Consent is implied upon completion of the questionnaire. Confidentialityand anonymity will be assured at all times. I would appreciate yourapproval to undertake this study in the hospital.


Yours faithfully,

Ciara Kelly.



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APPENDIX 3

Questionnaire for student nurses

(Adapted from Roses (1997) questionnaire survey on violence and

aggression towards nursing staff in the accident and emergency department

Violence and aggression while on placement.

Please tick the box that applies to you:

1: Sex Female Male

2: Age 18-25 26-30 30+

3: Have you ever been abused by a patient or relative while working in

the hospital? Was it physical or verbal abuse Verbal physical

both?

4: If so, how many times?

Never 1-3 4-9 10-15 15+

5: How long ago was the most recent incident?

0-3mths 4-6mths 7mths-1yr 2-4years

6: What clinical area did it occur in?

A&E Female ward Male ward Mixed Gender Ward

Care of the elderly patient

7: Was it: Day duty Night Duty

8: Did you take sick leave? Yes No.

If yes state how long

9: What day of the week was it? Monday Friday Weekend

10: Did you report the incident and if so was the response helpful?Yes No



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11: Do you worry about being verbally or physically abused while on

placement? Yes No

What do you think was the causative factor in the violent andaggressive act?

Did the incident question whether you wanted to, or felt able tocontinue on in the course? (Please explain in detail).



29

Appendix 4

Ms Mary Rose

24 XXXX Estates

1ST March.

Dear Mary,

My name is Ciara Kelly and I am currently in my fourth and final year ofGeneral Nursing in Trinity College Dublin. As part of my final piece ofacademic work for college I am required to conduct a research proposal.The study I intend to undertake is a quantitative study using astructured questionnaire. My aim is to determine the incidence ofviolent and aggressive acts towards student nurses and to investigatethe factors that facilitate violent acts to occur. When conducting my

literature review I came across your article: A survey of violencetowards nursing staff in one large Irish Accident and Emergencydepartment and noticed that you used a questionnaire to gather yourdata. I am asking for your permission to use your questionnaire as partof my research proposal. I will have to slightly adjust some parts inorder to make it relevant to my proposed study by adding in somequestions of my own.

I would really appreciate your approval to do so and complete myresearch proposal.

Yours Sincerely,Ciara Kelly.

Appendix 5



30

Cover Letter to Participants.

1st March

Dear Sir/Madam,

I am currently in my fourth and final year of General Nursing in Trinity

College Dublin. As part of my final piece of academic work for college Iam required to conduct a research proposal. The study I intend toundertake is a quantitative study using a structured questionnaire. Myaim is to determine the incidence of violent and aggressive acts towardsstudent nurses and to investigate the factors that facilitate violent actsto occur.The study comprises of 100 General Nursing students from this hospitaland another 100 from a different teaching hospital in Ireland andparticipants are invited to complete a simple questionnaire which willhopefully yield findings of relevance to the study. The inclusion criteria

for the study states that the sample of nursing students must be in their4th year of the general nursing degree and have completed their A&Eplacement.

(Saines 1999) defines violence as any episode which puts a health careworker at risk and it includes verbal abuse, threatening behaviour orassault by a patient.

Aggression is described as animosity or hostility shown towards anotherperson as a response to frustration or opposition (Burr et al. 1998).

There is very little research conducted on the incident of violent andaggressive acts towards student nurses. If you would like to take part inthis study, you will be required to complete the questionnaire andreturn it in the stamped addressed envelope which will be sealed forconfidentiality. I have assigned a gatekeeper to this study to ensureconfidentiality and reduce researched bias. Consent for the study will beimplied upon completion of returned questionnaires. You may withdrawfrom the study at any stage.


Yours sincerely,

Ciara Kelly.

Appendix 6



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Reminder Letter.

Dear Sir/Madam,

I am writing to give a gentle reminder to complete your questionnaire ifyou have not already done so. Upon completion the questionnaire

should be sent in the stamped addressed envelope. Your anonymity andconfidentiality is guaranteed at all stages and should you wish towithdraw from the study at any stage you may do so.


Yours Sincerely,

Ciara Kelly.

Appendix 7



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Time Scale.

Month jan feb mar apr may jun jul aug sep nov dec jan feb mar apr may

literature

ethics

sample

pilot

data coll

analysis

findings

Finished.

In progress

Appendix 8



Budget.

Expenditure: Cost

Personnel

Gatekeeper salary (2 months salary @ 65 per day.

Statistician and SPSS

3,900

3,000

Materials

Stationary

Photocopying / Printing/ Ink Cartridges etc.

Postage and envelopes

USB

45.00

25.00

150.00

10.00

Presentation

Binding of finished research

leaflets

Internet and Telephone Costs

20.00

40.00

50.00

Total 7240.00

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