Marquette Universitye-Publications@MarquetteCollege of Nursing Faculty Research andPublications Nursing, College of

1-1-2013

Verbal Abuse of Pediatric Nurses by Patients andFamiliesAnn TrumanKosair Children's Hospital

Myra GoldmanUniversity of Louisville

Carlee LehnaUniversity of Louisville

Jill BergerNorton Healthcare

Robert V. ToppMarquette University, robert.topp@marquette.edu

Published version. Kentucky Nurse, Vol. 61, No. 1 ( January-March 2013): 6-8. Publisher Link. ©2013 Kentucky Nurses Association. Used with permission.

Page 6 • Kentucky Nurse January, February, March 2013

Verbal Abuse of Pédiatrie Nurses by Patients and FamiliesAnn Truman

Kosair Children's HospitalMyra Goldman and Carlee Lehna

University of LouisvilleJill Berger

Norton HealthcareRobert Topp

Marquette University

Abstract

ObjectiveThe purpose of this study was to determine the

extent to which nurses practicing in a pédiatriehospital encounter verbal abuse by patients andfamilies and their reactions to this abuse.

BackgroundVerbal abuse, the most common type of workplace

violence against nurses results in declining moraleand job satisfaction, and can negatively impactnurse turnover and quality of patient care.

MethodsThe study employed a concurrent triangulation

strategy using mixed methods. The 162 nurses whovolunteered completed a 3-part questionnaire, and asubgroup participated in one of three focus groups.

ResultsEighty-two percent of subjects reported verbal

abuse an average of 4 times per month. The majorityof these continued to think about the incident fora few hours (25%), a few days (36%), or a week ormore (12%). Nearly half reported feeling angry orpowerless and 14% said they thought of leaving theirposition.

ConclusionsThe findings of this study described the

nature and scope of the problem, and promptedimprovement in processes and education to supportnurses.

This study was motivated by nurses employedat an urban children's hospital reporting increasedincidences of verbal abuse by patients and families.These nurses told of negative encounters whichproduced feelings of frustration. They perceivedthat the hospital's increased emphasis on patientand family satisfaction prevented them from settinglimits on verbal abuse perpetrated by patients andfamilies. Nursing administration, concerned aboutstaff morale, proposed a study that would describethe extent to which nurses practicing in a pédiatriehospital encounter verbal abuse by patients andfamilies and their reactions to this abuse.

Review of the LiteratureThe threat of violence is an increasing concern for

nurses in the workplace. Between 1993 and 1999,nurses in the United States experienced a higherrate of work related violence (22 per 1,000 workers)than any other healthcare professional (Durhart,2001). Studies have demonstrated that nurses aresubjected to physical, emotional and verbal abusein their workplace settings by patients, patient'sfamilies, physicians, administrators, fellow nursesand other healthcare workers (Judkins-Cohn, 2010).While a majority of studies have focused on abuse ofnurses in the emergency and psychiatric settings,this is a problem that affects nurses across allspecialties and settings (Crilly, Chaboyer, & Creedy,2004, Henderson, 2003, Levin, Hewitt, & Misner,1998, Rowe & Sherlock, 2005).

Abuse among nurses has been studied byresearchers on both sides of the Atlantic (Lanza &Kayne, 1995, Libscomb & Love, 1992, Roach, 1997,Whittington, 1997). A multinational study by Poster(2006) compared the incidence of abuse betweenpsychiatric nurses in the United Kingdom, UnitedStates, Canada and South Africa. The results ofthis study found that a majority of the sample(75%) reported being physically abused at leastonce during their careers. Only 62% responded thatthey felt safe in their work environment most of thetime. These findings indicate that nurses are clearlyjustified in being concerned for their physical safetyand well-being. Additionally, research supportsthat incidents of physical abuse against nurses areunderreported (Lanza & Kayne, 1995, Libscomb &Love, 1992, Poster, 2006).

Verbal abuse Is the most common form of abuseexperienced by nurses. Duncan et al. (2001) notedthat nurses report only one in five incidents of verbal

abuse. Cameron (1998) found that 85% of nursesreported experiencing verbal abuse in their job, 45%of whom had experienced such abuse in the past15 days of work. In 2001, a Canadian survey foundthat over 50% of front-line nurses had been verballyabused and 22% reported physical abuse within theprevious 12 month period ("Nurses report abuse,"2001). A more recent study in Canada examinedverbal abuse among pédiatrie nurses and found that94% had been a victim of verbal abuse at least onceduring a three month period (Pejic, 2005). A studyof verbal abuse among nurses in Turkey found that86% reported having been verbally abused withina 1 year period (Uzun, 2003). Maguire and Ryan(2007) surveyed 87 Irish mental health nurses ofwhich 80% had experienced non-threatening verbalabuse and 54% had experienced threatening verbalabuse at work in the last month. In a study thatsurveyed 2,487 Australian nurses, 65% reportedexperiencing emotional abuse in the last 5 shiftsthey had worked, with the majority of abuse comingfrom the patients under their care (Roche, Diers,Duffield, & Catling-Paull, 2010). Jonker, Goossens,Steenhuis and Oud (2008) examined the incidenceof abuse experienced by nurses practicing in theNetherlands. They found that younger and lessexperienced nurses were more likely to experienceabuse at work compared to their more experiencedcounterparts. A study conducted in the UnitedStates by May and Grubbs (2002) concluded that50% of nurses who experience verbal abuse bycognitively impaired patients or patients undergoingsubstance withdrawal overlook the verbal abuse. Inaddition, 48% noted that they had never filed anywritten reports regarding verbal abuse from familymembers and/or visitors.

A limited number of studies have indicated thatverbal abuse experienced by nurses may negativelyimpact their morale and job satisfaction, sometimesresulting in turnover (Anderson, 2002, Cameron,1998, Gates, Fitzwater, & Meyer, 1999. Pejic, 2005)Walrath, Dang, and Nyberg (2010) reported that48% of the nurses interviewed in focus groups knewof a nurse who had transferred to a different unitor department because of experiencing verbal orphysical abuse Thirty-four percent of their samplestated that they knew nurses who had left theorganization due to experiencing abuse. Turnover iscostly to organizations and can negatively impact thequality of patient care.

Purpose and Research QuestionsThe purpose of this study was to determine the

extent to which nurses practicing in a pédiatriehospital encounter verbal abuse by patients andfamilies and their reactions to this abuse. Thispurpose will be addressed by answering thefollowing research questions:

1. How often do nurses practicing in a pédiatriehospital encounter verbal abuse by patientsand families?

2. Among nurses practicing in a pédiatriehospital who encounter verbal abuse, whatare their reactions and responses to thisabuse?

Methods

DesignTo address these research questions, a descriptive

study was conducted using quantitative andqualitative approaches to obtain data. The studywas reviewed by the organization's InstitutionalReview Board and determined to be exempt fromfurther review. Registered nurses were recruitedfrom a single pédiatrie hospital to participate in thequalitative and/or quantitative components of thestudy. Individuals who volunteered to participatein the quantitative component anonymouslycompleted two questionnaires. These questionnairesincluded a background questionnaire and a paperand pencil instrument concerning the degree,type, frequency and outcomes of verbal abuse theymay have experienced by patients and/or theirfamilies. Nurses who volunteered to participate inthe qualitative component participated in focusgroups of 6-8 participants each and discussed theirexperiences of verbal abuse in a collective setting.Focus groups took place in the hospital away fromthe nurses' normal work environment. The contentof the focus group meetings were audio recordedand field notes were kept by the two research nursescoordinating the focus groups, who were not hospitalemployees. The focus group discussions were guidedby the research questions.

SampleRegistered nurses (RNs) employed full or part

time in direct care roles were recruited to participatein the study by placing survey packets on everynursing unit. Potential participants were encouragedby members of the nursing research council tocomplete the packet. A box was placed on eachunit to collect the anonymously completed surveys.Twenty nurses from throughout the institutionvolunteered to participate in three focus groups.Participants for these focus groups were solicitedby non-hospital employee members of the researchteam attending unit-based nursing council meetingsand explaining the study. Following this explanationmembers of the group were invited to participate inthe focus groups.

InstrumentsTwo instruments were used to collect quantitative

data from the sample. A 10-item questionnaire wasused to collect background information about thesubjects. Data about verbal abuse by patients and/or their families were gathered through the nursescompleting a second paper and pencil instrument.This second instrument was adapted from thetool developed by Rowe & Sherlock (2005) andstudied by others (Oweis & Diabat, 2005, Pejic,2005) which explored the types, frequency andresponses to verbal abuse of nurses by other nurses.The instrument developed by Rowe & Sherlockcombined the Verbal Abuse Survey developed byCox (1987) and the Verbal Abuse Scale developedby Manderino and Berkey (1997). This instrumentyielded six characteristics of nurse on nurse verbalabuse including the type and frequency of verbalabuse, the emotional reactions to the verbal abuse,cognitive appraisal of the encounter, the copingbehaviors used, the effectiveness of the coping,and the long-term negative effects of the abuse.Since nursing staff were asked to complete thesurvey during their working shift, the presentstudy employed only 3 of these subscales to studyfrequency of verbal abuse, emotional responsesand coping behaviors. Furthermore, participantswere asked to complete the survey in the context ofverbal abuse by patients and families rather thanother healthcare providers. Eight separate types ofverbal abuse were listed on the frequency subscale.Respondents were asked to indicate the frequencywith which they experienced each type of verbalabuse in the previous 12 months on a 0-6 scale(O=never, l=one to six times per year , 2=once permonth or less, 3=several times a month, 4=onceper week, 5=several times a week, 6=every day).Seventeen emotional responses were listed andsubjects were asked to rate the degree to whichthey reacted emotionally when they experiencedverbal abuse from a patient or family member on a0-6 scale (0=Not at all, l=Very mild feeling, 2=Mlld,feeling, 3=Moderate feeling, 4=Strong feeling, 5=Very strong feeling, 6=Extreme feeling). Finallytwelve coping responses were listed and subjectswere asked to indicate the degree to which theirthinking was similar to the thoughts listed as theyevaluate the verbal abuse on a 0-6 scale (0=Notsimilar at all, l=Slightly similar, 2=Mildly similar,3=Moderately similar, 4=Similar, 5=Very similar,6=Extremely Similar).

Three focus groups consisting of 6-8 differentregistered nurses lasting no more than an hour eachwere conducted to collect qualitative data to addressthe research questions. Six open-ended questionswere used to stimulate discussion in the focusgroups. These included:

1. Describe some of the most frequent forms ofabuse to nurses seen at this hospital?

2. Tell me about the reasons why you believenurses perceive they are abused?

3. What are the nurses' most common responsesto being abused? Please describe an example.

4. Whom do you see most often abusing thenurses?

5. Abuse causes what to the nurses?6. What are some suggestions to help prevent

abuse to the nurses?Focus groups were held at the hospital in meeting

rooms that were away from the units and wereconducted by non-hospital personnel to facilitatecandid discussion.

Verbal Abuse of Pédiatrie Nurses continued on page 7

January, February, March 2013Verbal Abuse of Pédiatrie Nurses continued from page 6

Data Analysis

Quantitative Data AnalysisOnce the questionnaires were collected a

codebook was developed for closed ended questionsto provide numerical results for analysis. Data weretranscribed from questionnaires to excel spreadsheets and double entered to identify transcriptionerrors. Descriptive statistics, including frequenciesand percentages, were calculated to describe thedemographics and verbal abuse experienced by thesample.

Qualitative Data AnalysisFocus groups (FG) were held shortly after the

surveys were collected. The senior qualitativeresearcher recorded field notes upon completionof the first FG session. Subsequent sessions wereconducted by two qualitative researchers. Aftereach FG session, the audio-taped dialogue wastranscribed verbatim; transcriptions were verified foraccuracy by listening to the tapes at the same timethe transcriptions were read. Thematic analysis wasbegun immediately and findings from a previous FGsuggested additional questions for the next session.

Credibility was determined through memberchecking. This allows for the participants insubsequent groups to verify thematic responsesfound in previous sessions (Cresswell, 2008, Lincoln& Guba, 1985). Descriptions from collected datawere used to triangulate quantitative findings.Researcher biases were minimized by presentingthe results to the members of the nursing researchcouncil. Peer debriefing enhanced the accuracy ofthe participant responses. These methods ensuredthe trustworthiness of the qualitative findings.

ResultsA total of 162 nurses representing all areas of

the hospital and all shifts completed the surveys.Their mean age was 38.6 years. They had beennurses an average of 13.7 years and employed inthis hospital an average of 10.81 years. Participantswere predominately female (98%) with the majorityholding a baccalaureate degree (61%), working fulltime (73.5%) and on day shift (63%). The 29 nursesparticipating in the focus group reported a meanage of 41 years. They had been a nurse an average of17.95 years and in their current position an averageof 7.27 years.

In answer to research question 1, "how often donurses practicing in a pédiatrie hospital encounterverbal abuse by patients and families?" the medianresponse was 2 times per month (see Figure 1).TWenty-five nurses (15.4%) reported no instances ofverbal abuse. Ninety-three nurses (57.4%) reported1-3 instances per month. There was a differencebetween day shift and night shift for frequency ofverbal abuse (p=0.018). There was no differencebetween units.

Research question 2 asked, "among nurses

Figure 1: Distribution of frequency of verbal abuseevents per month

Number of verbal abuse events in 1 month50 -i 46 —

40

30 Í2S-

20

31

• ' 1 & -S Frequency

10 I 1o

o 2 4 6 8 12 25 100

practicing in a pédiatrie hospital who encounterverbal abuse, what are their reactions and responsesto this abuse?" The top four reactions are anger(25.9%), determination to problem solve (23.5%),powerlessness (16%) and embarrassment (11.7%)(see Figure 2). Eighty-two percent (82%) continuedto think about the incident for a few hours (25%),a few days (36%) to more than a week (12%) (seeFigure 3). In addition, 14% of the sample reportedthat they have contemplated leaving their positionafter a verbally abusive incident. Sixty-five percentof the sample perceived that they handled abusivesituations well, citing the use of 3 techniques: basicassertiveness (30%), conflict resolution (31%) and co-worker support (20%).

Focus group resultsMajor thematic units corresponded directly

with quantitative subscale findings and previousresearch. Participants reported feeling that abusivebehavior has increased in recent years. Theyrelated that the focus on patient satisfaction hasled to a belief among nurses that administrationwould always side with the patient or family in adispute. This belief leads to an increased senseof powerlessness to set limits and assertivelyhandle abusive behavior. Participants relayedan understanding that patients and parents arestressed when in the hospital, but stated that overtime they lose the ability to be the outlet for thatstress. Many in the group felt that verbal abusecaused decreased job satisfaction, low self-worthand burnout, and reported that they have knownnurses who quit their jobs in response to repeated

Figure 2: Reactions of nurses to verbal abuse events

Nurses'

4 035302 52 01 51 0

5 •

0 ^ —

Reactions to Verbal Abuse

— - •""" " 1l ' i ~^^| —^^J——^jj——^^J—

- • " iMüi ^B" "^B ^B ^H ^H

* # ^ «sS^ <f « <** s»"" d^'^'o* 4?^ dí^ «^ >.*^ • ^

Kentucky Nurse • Page 7Figure 3: Nurses' report of how long they continue tothink about verbal abuse after the incident

How Long Nurses Think aboutVerbal Abuse Incident

i Frequency

verbal abuse. Participants stated that they lookto their colleagues for support, and were aware ofother resources available such as risk management,pastoral care, and employee assistance.

DiscussionBoth the quantitative and qualitative analyses

lend support to the research stating that verbalabuse has a negative Impact on morale and jobsatisfaction, and can affect job performance andthe quality of patient care. It further supports thatverbal abuse can have an impact on the organizationthrough increased staff turnover and poor retentionrates (Anderson, 2002, Bowers et al., 2006,Cameron, 1998, Gates et al., 1999, Gerberich et al.,2004, Pejic, 2005, Ryan et al., 2008).

Nurse participants described feeling that nochange would occur with the reporting of verbalabuse due to the prevailing attitude that thecustomer is always right. This supports previousfindings from the literature documenting that onlyone in five Incidents of verbal abuse is ever reported(Duncan et al., 2001, Jonker. Goossens, Steenhuis,& Oud, 2008).

Findings from the focus groups were used toguide the implementation of hospital wide solutions.Participants provided suggestions that ranged fromuse of multi-disciplinary teams to de-escalate anabusive situation, to personal training on how bestto handle these events. One staff nurse stated, "...Iurge any staff member to report verbal abuse when ithappens or the culture will not change. There needsto be documented evidence to support the incidenceof abuse in order for those not at the bedside to knowthe gravity of the problem."

Implications for NursingA presentation of the research study and findings

at a hospital nursing grand rounds resulted in afrank discussion between bedside nurses and nursemanagers about the current work environment.Nurses reinforced the research findings and agreedthat many times the verbal abuse by patients andfamilies was not reported because nurses felt no

Verbal Abuse of Pédiatrie Nurses continued on page 8

HigginsHealth Care Institute

Toll Free: 855-891-7356

Schedule includes:• Breakout Sessions by Discipline• Private Cocktail Event at Rock & Roii Hail of Fame with Exclusive Concert• Lake Erie Cruise on the Goodtime iii - Cieveiand's Largest Excursion Ship• Shutties to Honeshoe Casino• Tour at the Greater Cie raiand Hquarium• Expert Speakers • Raffle Prizes

urn Call as today or visit oar Eirants Page at:

www.higginshealthcare.coni

NURSES - JOIN US FOR A FUN-FILLEDGiving all practicing APNs, RNs, LPNs and Student Nurses, throughout the

United States, an opportunity to network with other professionals. CEU's Awarded.

Page 8 • Kentucky NurseVerbal Abuse of Pédiatrie Nurses continued from page 7

action would be taken. Managers reassured nursesthat they would be supported, and encouraged themto report any verbally abusive situations. The chiefnursing officer asked all directors and managers tohave discussion with staff on their units in formaland informal meetings to assure nurses that verbalabuse will not be tolerated and should be reported.

The findings of the study were also presented tothe hospital's Safety and Executive teams. Theseteams expressed concerns over the nurse notreporting verbal abuse situations and attempting tomanage these on their own. These groups suggestedseveral educational programs and resources toassist the nurse in these situations. Nurses arenow encouraged to formally report a verbal abuseencounter through the Patient Safety ReportingSystem (PSRS) to ensure that Risk Managementand nurse leaders are aware of the incident and canprovide follow up with the nurse as needed.

In the two years following the study severaleducational programs were developed and madeavailable to staff to assist them in the managementof verbally abusive encounters. An interactiveprogram was developed which teaches nurses andphysicians how to communicate difficult informationwith patients and families. This program helpshealthcare providers to strengthen and hone theircommunication skills in difficult situations by usingactors to portray family members and videotapingsimulated patient encounters. Through critique ofthe videotapes participants learn better strategies tomanage difficult conversations or deescalate angrybehavior (Peterson, Porter, & Calhoun, in press).

Additional programs at nursing grand roundshave focused on de-escalation, crisis prevention,personal safety and how to set limits withpatients and families. These programs give nursesinformation on how to handle an abusive situation,who they can call for help, and what resourcesare available to assist nurses to deal with negativefeelings after a verbal abuse encounter.

In an effort to strengthen the new nurse's skilllevel and understanding, the orientation lecture onService Excellence was enhanced. In addition toemphasizing the importance of giving patients andfamilies the best experience possible, the educatorpoints out that nurses have a right to be treatedwith respect and are not expected to tolerate verbalabuse or threatening behavior. If any type of abuseoccurs, the nurse should seek consultation withthe assistant nurse manager or nurse manager andreport the abuse in PSRS.

ConclusionThe hospital's intense focus on increasing patient

satisfaction scores was interpreted by the nursingstaff as "the patient is always right, no matter what".Consequently, nurses involved in encounters ofverbal abuse rarely reported them, so nurse leaderswere not aware of the extent of the problem. Thisstudy provided nursing leadership with valuable

information about the extent of the problem, aswell as the impact and possible steps to correct it.Several educational and process measures have beenimplemented since completion of the study. A secondshorter survey is under consideration to determineif the efforts of the past two years have made animpact on nurses' coping strategies and perceivedsupport from nursing leadership.

References

Poster, E. C. (2006). A multinational study ofpsychiatric nursing staffs beliefs and concernsabout work safety and patient assaults. Archives ofPsychiatric Nursing, J0(6), 365-373.

Anderson, C. (2002). Workplace violence: Are somenurses more vulnerable? Issues in Mental HealthNursing, 23(4), 351-366.

Bowers, L.. Simpson, A., Eyres, S., Nijamin, H.,Hall, C, Grange, A., & Phillips, L. (2006). Seriousuntoward incidents and their aftermath in acuteinpatient psychiatry: The Tomkins acute wardstudy. International Journal of Mental HealthNursing, J5(4), 226-234.

Cameron, L. (1998). Verbal abuse: A proactiveapproach. Nursing Management, 29(8), 34-36.

Cox, H. C. (1987). Verbal abuse in nursing: Report ofa study. Nursing Management, 22, 47-50.

Cresswell, J. (2008). Research design: Qualitative,quantitative, and mixed methods approach.Newbury Park, CA: Sage.

Crilly, J., Chaboyer, W., & Creedy, D. (2004). Violencetowards emergency department nurses bypatients. Accident and Emergency Nursing, 1212),67-73.

Duncan, S. M., Hyndman, K., Estabrooks, C. A.,Hesketh, K., Humphrey, C. K., Wong, J. SGiovannetti, P. (2001). Nurses' experience ofviolence in Alberta and Brittish Comumbiahospitals. Canadian Journal of Nursing Research,32(4), 57-78.

Durhart, D. T. (2001). National crime victimizationsurvey: Violence in the workplace, 1993-1999.Retrieved from https://www.ncjrs.gov/App/Publications/ab§tract.aspx?ID=190076

Gates, D. M., Fitzwater, E., & Meyer, U. (1999).Violence against caregivers in nursing homes:Expected, tolerated and accepted. Journal ofGerontological Nursing, 25(4), 12-22.

Gerberich, S. G., Church, T. R., McGovern, P. M.,Hansen, H. E., Nachreiner, N. M., Geisser, M.S.,...Watt, G. D. (2004). An epidemiological studyof the magnitude and consequences of workrelated violence: The Minnesota Nurses Study.Occupational and Environmental Medicine, 61{6],495-503.

Henderson, A. D. (2003). Nurses and workplaceviolence: Nurses' experience of verbal and physicalabuse at work. Canadian Journal of NursingLeadership, 16[4), 82-98.

Jonker, E., Goossens, P., Steenhuis, I., & Oud, N.(2008). Patient aggression in clinical psychiatry:Perceptions of mental health nurses. Journal of

When disaster strikes,who will respond?

The Kentucky Department for Public Health is seeking nurses to register and train as Medical Reserve Corps(MRC) volunteers. When events such as ¡ce storms, flooding or pandemics occur in Kentucky, our citizensneed nurses to provide compassionate care. Register co volunteer and receive training from your local MRCunit today. By doing so, you can be prepared to serve your community, family and neighbors when they needit most.

KlHELPSTo learn more, go online athttps://khelps.chfs.ky.gov

In times of need, Kentucky helps.

January, February, March 2013Psychiatric and Mental Health Nursing, 15(6), 492-499.

Judkins-Cohn, T. (2010). Verbal abuse: The wordsthat divide impact, impact on nurses and theirperceived solutions. Southern Online Journal ofNursing Research, iO(4), 234-247.

Lanza, M. L., & Kayne, H. I. (1995). A comparisonof patient and staff perceptions. Issues in MentalHealth Nursing, 16, 129-141.

Levin, P. J., Hewitt, J. B., & Misner, S. T. (1998).Insights of nurses about assaults in hospital-based emergency departments. Image: Journal ofNursing Scholarship, 30(3), 249-254.

Libscomb, J. A., & Love, C. C. (1992). Violencetowards health care workers: An emergingoccupational hazard. American Association ofOccupational Health Nurses, 40(5), 219-228.

Lincoln, Y., & Guba, E. (1985). Naturalistic inquiry.Newbury Park, CA: Sage.

Maguire, J., & Ryan, D. (2007). Aggression andviolence in mental health services: Categorizingthe experiences of Irish nurses. Journal ofPsychiatric and Mental HeaUh Nursing, 14(2], 120-127.

Manderino, M. A., & Berkey, N. (1997). Verbalabuse of staff nurses by physicians. Journal ofProfessional Nursing, 13(1], 48-55.

May, D. D., & Grubbs, L. M. (2002). The extent,nature and precipitating factors of nurse assaultamong three groups of registered nurses in aregional medical center. Journal of EmergencyNursing, 28(1], 11-17.

Nurses report abuse by patients, families. (2001,October 25). The Globe and Mail, p. A5.

Oweis, A., & Diabat, K. M. (2005). Jordanian nurses'perception of physicians' verbal abuse: Findingsfrom a questionnaire survey. International Journalof Nursing Studies, 42(8], 881-888.

Pejic, A. R. (2005). Verbal abuse: A problem forpédiatrie nurses. Pédiatrie Nursing, 31(4], 271-279.

Peterson, E. B., Porter, M. B., & Calhoun, A, (Inpress). A needs-assessment based curriculum forthe navigation of relational crises in medicine.Journal of Graduate Medical Education.

Roach, L. (1997). Violence at work. Nursing Standard,12(5], 22-23.

Roche, M., Diers, D., Duffield, C, & Catling-PauU,C. (2010). Violence toward nurses, the workenvironment and patient outcomes. Journal ofNursing Scholarship, 42(1), 13-22.

Rowe, M. M., & Sherlock, H. (2005). Stress andverbal abuse in nursing: Do burned out nurseseat their young? Journal of Nursing Management,13(3], 242-248.

Ryan, E. P., Aaron, J., Burnette, M. L., Warren,J., Burket, R., & Aaron, T. (2008). Emotionalresponses of staff to assault in a pédiatrie statehospital. Journal of the American Academy ofPsychiatry and the Law, 36(3), 360-368.

Uzun, O. (2003). Perceptions and experiences ofnurses in TVirkey about verbal abuse in clinicalsettings. Journal of Nursing Scholarship, 35(1], 81-85.

Walrath, J., Dang, D., & Nyberg, D. (2010). HospitalRNs' experiences with disruptive behavior: Aqualitative study. Journal of Nursing Care Quality,25(2], 105-116.

Whittington, R. (1997). Violence to nurses:Prevalence and risk factors. Nursing Standard,12(5], 49-56.

Earn a Credential That's• "Top 15" ranked nursing school

• Practice specialties for all interests

• State-of-the-art nursing informaticsand facilities

• Community of scholars with broadfaculty expertise

• Distance learning opportunities• New BSN to DNP option

VANDERBILT UNIVERS

in Demand Nationwide;• Master of Science in Nursing (MSN)

'.• Doctor of Nursing Practice (DNP)

"* PhD in Nursing Scienceclinical interventions, health services research

Learn more. Apply todaywww.nursing.vanderbiit.edu

TY %J School of Nursing

mUm V H 9 Vanderbik is an equal opportunity affirmative action university.