wounding words: swearing and verbal aggression in an inpatient setting

Wounding Words: Swearing and Verbal Aggression in anInpatient Settingppc_295 194..203

Teresa Stone, RN, RMN, BA, MHealth Management, PhD, Margaret McMillan, RN, BA, M Curr St (hons),PhD, OAM, Michael Hazelton, RN, BA, MA, PhD, and Edward H. Clayton, BRurSci, PhD

Teresa Stone, RN, RMN, BA, MHealth Management, PhD, is the program convenor for the Bachelor of Nursing; Margaret McMillan, RN, BA, M Curr St(Hons), PhD, OAM, is a Conjoint Professor; Michael Hazelton, RN, BA, MA, PhD, is Professor of Mental Health Nursing; University ofNewcastle—Nursing and Midwifery, Newcastle, New South Wales, Australia; and Edward Clayton, BRurSci (Hons) PhD, is a Livestock Research Officerwith Industry & Investment NSW at the Wagga Wagga Agricultural Institute, Wagga Wagga, New South Wales, Australia.

Search terms:Aggression, inpatient mental health, OvertAggression Scale, swearing, verbal aggression

Author contact:[email protected];[email protected], with acopy to the Editor: [email protected]

First Received December 22, 2009; FinalRevision received September 9, 2010;Accepted for publication September 9, 2010.

doi: 10.1111/j.1744-6163.2010.00295.x

PURPOSE: The aim of the research was to investigate swearing and verbal aggres-sion in Australian inpatient settings, including incidence, gender, patient motiva-tion, and nursing interventions.DESIGN AND METHODS: A mixed methods approach utilizing the Overt Aggres-sion Scale and a survey of 107 nurses’ perceptions of their experience of swearing wasused.FINDINGS: High levels of swearing and verbal aggression were found, with differ-ing patterns for male and female patients. Nurses subjected to swearing experiencedhigh levels of distress, especially females.All nurses appeared to use a limited range ofinterventions to deal with patient aggression.PRACTICAL IMPLICATIONS: In order to provide optimal care for patients, there isa clear need to improve nurses’ ability to predict and prevent aggression.

Nurses are, of all health workers, most likely to be targetsof verbal aggression (Chen, Hwu, & Williams, 2005; Gillies& O’Brien, 2006; National Audit Office, 2003), and thereis evidence that nurses are regularly exposed to verbalabuse, aggressive incidents, and agitated behavior. Data froman American study of 213 nurses in a large teaching hospitalindicated that more than 96% had experienced verbalabuse: 79% reported having been abused by patients, 75%by other nurses, 74% by doctors, and 68% by patients’ fami-lies (Rowe & Sherlock, 2005). Uzon (2003), in a study ofTurkish nurses, found that 100% of nurses working in psy-chiatric settings had experienced verbal aggression. Similarhigh rates were found in emergency (98%) and pediatricsettings (96.9%) compared with an average of 86.7%overall.

Despite widespread under-reporting, it is likely that theincidence of verbal aggression is rising (Sofield & Salmond,2003). A survey of 4,481 nurses in the United Kingdomrecorded that more than half of those assaulted orharassed by patients did not report the incident (RoyalCollege of Nursing, 2002), possibly because of perceptionsthat reporting would not lead to service improvements, and

that nurses involved might face further trauma if the causesof aggression were attributed to them (Jones & Lyneham,2000).

These reports of verbal aggression contain no dataregarding the context of the aggression or the nurses’response. Little information is available about the role ofswearing in relation to verbal aggression, or whether swear-ing alters or intensifies the experience for nurses. Swearing,when mentioned in the literature, is invariably treated asnegative (Stone, 2009), with no detailed examination of thetherapeutic relationship between nurses and patients. Swearwords are those that refer to something that is taboo, offen-sive, impolite, or forbidden in the culture; can be used toexpress strong emotions, most usually of anger; may evokestrong emotions, most usually of anger or anxiety; includethe strongest and most offensive words in a culture—stronger than slang and colloquial language; and may alsobe used in a humorous way, and can be a marker of groupidentity (adapted from Andersson & Trudgill, 1990, p. 52).No research has been conducted into levels of swearing inthe health workplace, a deficit that this study was designedto address.

Perspectives in Psychiatric Care ISSN 0031-5990

194 Perspectives in Psychiatric Care 47 (2011) 194–203 © 2011 Wiley Periodicals, Inc.

Background

Nurses in psychiatric inpatient facilities regularly encounteraggression, and verbal aggression is the most commonlyreported form. A study of 316 aggressive incidents in aforensic setting (Daffern, Mayer, & Martin, 2006) indicatedverbal aggression by patients (62% of incidents) as mostcommonly reported, followed by physical aggression againstothers (29.1%), and damage toward objects (8.9%). Thestudy indicated that physical aggression was likely to be pre-ceded or accompanied by verbal aggression. Felson andSteadman (1983), in a study of criminal violence, suggestedthat verbal aggression often precedes threats and physicalattack.

Many perceived “causes” of aggression have been reported.A review of 45 aggressive incidents in mental health inpatientfacilities reported three main causes: patient illness, includinginsufficient medication and delusions; interpersonal con-flicts; and limit setting, such as being prevented from leavingthe hospital (Ilkiw-Lavalle & Grenyer, 2003). Staff, in a studyof 385 aggressive incidents, identified mental state as the mostlikely cause of aggression (65.7% of incidents); patient admis-sion status, for example, being involuntary, accounted for9.6%; and being in a confined environment was responsiblefor 6.2% (Barlow, Grenyer, & Ilkiw-Lavalle, 2000). Contextualdetail is lacking, however, about the therapeutic regimen inwhich the incidents occurred.

In reviewing the literature on causal models of aggression,Duxbury (2002, p. 326) identified three explanatory frame-works: an internal model, focusing on individual patientcharacteristics such as age, gender, diagnosis, and substancemisuse; an external model, highlighting environmentalfactors such as overcrowding, lack of privacy, under- andoverstimulation, unit design and routines, and staff charac-teristics; and a situational model, emphasizing interactions.In a retrospective study of 130 incidents of aggression, 60%were classified as having been precipitated externally and 40%attributed to internal factors (Shepherd & Lavender, 1999). Itis increasingly accepted that challenging behavior, includingaggression, should be viewed as a product of several inter-linked factors: the patients; the nurses; the situation, includ-ing its culture and working practice in which the behavioroccurs; and the physical environment (Farrell, Shafiei, &Salmon, 2010).

How health professionals cognitively appraise challengingbehavior is thought to influence the way in which theyrespond to it emotionally and behaviorally, and the meaningsnurses attribute to the causes of aggressive behavior affecthow they respond to and manage verbal and physical aggres-sions (Bailey, Hare, Hatton, & Limb, 2006). If the cause of aperson’s problem is perceived to be internal, an observer isless likely to respond with helping behavior (Ogden & Knight,1995; Wanless & Jahoda, 2002).

Little literature exists on the link between swearing andpsychiatric conditions commonly seen in inpatient mentalhealth units. However, Jay (1999) explored associationsbetween swearing and conduct disorder, antisocial personal-ity disorder, and schizophrenia, but his observations lackedan evidence base. The occurrence of verbal aggression inpatients diagnosed with schizophrenia, bipolar affective dis-order (BAD), and personality disorders was noted by Barlowet al. (2000). Patients with schizophrenia and BAD were sig-nificantly more likely to be aggressive than those with otherdisorders, and schizophrenia was more likely to be associatedwith verbal than physical aggression.

Nurses respond in many ways to aggression. Owen, Taran-tello, Jones, and Tennant (1998b), in their prospective studyof aggressive behaviors in five Sydney acute mental healthunits, found “counselling” (defined broadly) to be the mostfrequently reported response to the 1,289 reported incidentsof aggression (n = 732). Other responses included medication(n = 357), removal from the immediate area (n = 272), physi-cal restraint (n = 242), physical seclusion (n = 72), and nofurther action was taken in 160 incidents (12%); the catego-ries were not mutually exclusive. In only a handful of caseswere aggressive patients relocated to other facilities.

Conflict resolution, problem solving, and de-escalation arerecommended as first-choice interventions for aggression ininpatient settings (The International Society of PsychiatricMental Health Nurses in Cowin et al., 2003). Restraint andseclusion are generally regarded as last resorts. Patientsemphasized the need for better communication in managingaggressive incidents, whereas staff often accentuate “medica-tion and medical management” in connection with bothcause of and response to aggression (Ilkiw-Lavalle &Grenyer, 2003, p. 392). However, pro re nata medication forshort-term management of aggression may not be properlyadministered or monitored by staff in psychiatric inpatientsettings (National Institute for Clinical Excellence, 2005, p.155).

Information is scarce about the perceived causes of aggres-sion in Australian inpatient settings. In particular, littleresearch has examined the relationship between perceivedcauses of verbal and physical aggressions and the nurses’responses to that aggression. For example, the use of counsel-ing or medication, when the perceived cause of aggression isinternal rather than external, has not been widely studied.Understanding how individuals cope with aggression isessential to developing techniques to improve responses tothat aggression, and to reduce the impact of aggression onnurses.

Purpose

The aim of the research was to investigate swearing and verbalaggression in Australian inpatient settings: first, to examine

Wounding Words: Swearing and Verbal Aggression in an Inpatient Setting

195Perspectives in Psychiatric Care 47 (2011) 194–203 © 2011 Wiley Periodicals, Inc.

whether reported incidents of verbal aggression were relatedto patient characteristics such as gender, or diagnosis, or theseverity of aggression; secondly, to explore the relationshipbetween verbal aggression and physical aggression, and staffperceptions of patient motivation; thirdly, to determine thenature of interventions nurses used in response to aggressionand whether interventions used varied with perceived causesof aggression; finally, to identify the relationship betweenswearing and verbal aggression, and the impact of both onnurses.

Methodology

A mixed methods approach (Borbasi, Jackson & Langford,2008; Johnson & Onwuegbuzie, 2004; Onwuegbuzie & Leech,2006) was adopted, involving quantitative analysis of retro-spective data drawn from an electronic patient informationmanagement system and a survey of current employees,which included qualitative response options. Ethics clearancefrom University and Area Research Ethics Committeesenabled the researchers to invite staff members to participatein the study and to utilize de-identified data from a databaseof aggressive incidents routinely maintained within an Aus-tralian Regional Mental Health Service.

Two instruments were used in the study: the Overt Aggres-sion Scale (OAS; Yudofsky, Silver, Jackson, Endicott, & Will-iams, 1986), which contains quantitative information onreports of verbal and physical aggressions, and the NursingSwearing Impact Questionnaire (NSIQ; Stone, 2009), whichcontains both quantitative and qualitative information on theresponses of nurses to swearing and verbal aggression. Thesequestionnaires capture differing information about theprevalence of aggression in mental health inpatient settingsand the impact of this aggression on nurses.

The OAS

The OAS is a standardized behavioral checklist that measuresthe frequency and severity of four categories of aggression,including (a) verbal aggression, (b) aggression againstobjects, (c) self-directed aggression, and (d) physical aggres-sion against others. Four items reflecting increasing levels ofaggression are specified. Items identify staff perceptions ofpatient motivation for aggression and interventions used fol-lowing the aggressive incident. The instrument has estab-lished validity and reliability (Beauford, McNiel, & Binder,1997; Malone, Delaney, Luebbert, Cater, & Campbell, 2000).Interclass correlation and coefficients range from 0.50 to 0.97for verbal aggression and 0.72 to 1.00 for physical aggression(Beauford et al., 1997; Malone et al., 2000).

OAS data were collected from facilities within the localpublic mental health services, including: a long-stay facilityincorporating rehabilitation beds, residential care for the

elderly experiencing mental health problems, and a forensicunit; an acute psychiatric inpatient facility for intensive care,adult psychiatry, dual diagnosis, and emergencies; and a12-bed child and adolescent psychiatric unit. The facilitiesserve a population of 840,000 individuals in industrial, urban,and rural areas.

NSIQ

The NSIQ is comprised of five parts with quantitative ratingscales and qualitative open-ended short-answer questionsseeking information on frequency, nature of, and responses tothe exposure of swearing as described previously (Stone,McMillan, & Hazelton, 2010). Nurses recorded the frequencyof exposure to swearing in six hypothesized work situationsand scored their perceived distress from this exposure on aLikert scale from 0 to 4; 0 being not distressed and 4 beingextremely distressed. Following ethics approval, a pilot studywas conducted to assess the feasibility and acceptability of theNSIQ. Ten nurses took part in the pilot study; seven were reg-istered nurses drawn from the participating units and theremaining three were nursing clinical leaders (Clinical NurseConsultants). Their feedback was sought by means of adebrief schedule about question acceptability, clarity, and theorder of the standardized measures on the NSIQ. The NSIQwas administered to 107 registered and enrolled nursesemployed in direct patient care in three healthcare settings—pediatrics, adult mental health, and child and adolescentmental health.

Data Analysis

The rate of aggression recorded on the OAS was calculated asthe number of incidents per 100 patient bed-days. Accordingto OAS guidelines, aggressive incidents occurring less than30 min apart were counted as part of the same episode. Thenumber of male and female inpatients was determined fromrecords of admissions on the last day of the calendar monthover the period of the study. Missing data from the OAS, suchas diagnoses and birth dates, were obtained by cross-checkingwith other patient data record systems. Diagnoses were codedinto major categories according to the Diagnostic and Statisti-cal Manual of Mental Disorders IV-TR (American PsychiatricAssociation, 2004). Differences in the rate of aggressive inci-dents per 100 patient bed-days between each level of verbal orphysical aggression against others were determined by analy-sis of variance using the general linear model (GLM) proce-dure in the SAS statistical program (SAS Institute Inc, 1997).The relative risk of aggressive incidents per 100 patient bed-days was examined using exact methods as a Poisson distribu-tion (Owen et al., 1998b). The relative risk (Zhang & Yu,1998) of aggression by females compared with males was cal-culated by Poisson regression with robust error variance



(Zou, 2004) using the GENMOD procedure in the SAS statis-tical program. The relationship between average levels ofverbal aggression and of physical aggression against otherswas determined by correlation analysis using SPSS GraduatePack v14.0 for Windows (Coakes & Steed, 2001).

The motivation for aggression was classified as either inter-nal or external according to the model of aggression proposedby Duxbury (2002, p. 326). Differences in the number ofaggressive incidents where an internal or external motivationwas attributed by staff were determined by analysis of varianceusingtheGLMprocedure inSAS.Differencesbetweenthetypeof intervention used (controlling or noncontrolling) for inci-dents of verbal aggression and physical aggression againstothers were determined by binomial regression using SPSS.

Differences in perceived distress experienced by nursesfrom exposure to swearing across the six hypothetical worksituations were analyzed by repeated measures analysis usingthe mixed model procedure in SAS (SAS Institute Inc, 1997).The restricted maximum likelihood estimation used “nursewithin setting” as the individual unit, “work situation” as therepeated item, and “nurse” as a random effect (Littell, Henry,& Amerman, 1998). The analysis determined the fixed effectsof clinical setting (mental health vs. pediatric), gender, andlevel of distress.

Qualitative data from the OAS forms and the NISQ wereanalyzed by (a) grouping under main thematic areas, and (b)using a priori coding, based on Duxbury (2002) and Duxburyand Whittington’s (2005) work on understanding inpatientaggression. Critical incidents and personal reports providedconfirmation of emergent themes. Categories emerged fromgrouped concepts with similar meaning or connotation

(Weber, 1990). Authenticity was established by presenting thedata to experienced Prevention and Management of Violencetrainers who verified processes.

Differences in quantitative responses from the NSIQregarding levels of distress for nurses from different settingswere analyzed by independent samples t-test using SPSS. Theuse of swear words by nurses was not normally distributed,and differences in the use of swearwords by male and femalenurses were determined by the nonparametric Mann–Whitney analysis in the SPSS statistical program.

Results

Included in the analysis were 9,623 OAS reports from January1996 to October 2005, completed for 384 (72.1%) males and148 (27.9%) females between 9.5 and 93.3 years of age (meanage = 45.6 years, SD = 21.00 years). Report forms totaling9,623, of which 5,998 (62.33%) were completed by males and3,625 (37.65%) by females, recorded 18,786 aggressive inci-dents because frequently the form reported more than one(see Table 1). Incidents of verbal aggression were most fre-quently reported, followed by physical aggression againstothers, then physical aggression against objects, with thefewest incidents being physical aggression against self (seeTable 1).

The average number of incidents per 100 bed-days permonth of verbal aggression at Level 3 (curses viciously, usesfoul language in anger, makes moderate threats to self andothers) and Level 4 (makes clear threats of violence towardothers or self, for example,“I’m going to kill you”) was signifi-cantly (p < .01) higher than the average number of incidents

Table 1. Rate of Aggressive Incidents per 100 Patient Bed-Days and the Relative Risk of Aggression by Females Compared with Males

Aggressiona

Rate of incidentsb Relative

(95% CI) p ValueeTotalc Male Female Riskd (Female : Male)

Verbal aggressionLevel 1 0.413 (� 0.03) 0.23 0.18 0.78 0.63–0.97 .024Level 2 0.343 (� 0.03) 0.14 0.20 1.38 1.11–1.71 .003Level 3 0.802 (� 0.03) 0.30 0.50 1.65 1.39–1.94 < .001Level 4 0.991 (� 0.03) 0.30 0.71 2.40 2.04–2.82 < .001Total incidents 0.97 1.59 1.63 1.41–1.89 < .001

Physical aggressionLevel 1 0.822 (� 0.03) 0.37 0.46 1.25 1.05–1.50 .014Level 2 0.931 (� 0.03) 0.40 0.54 1.34 1.14–1.57 < .001Level 3 0.303 (� 0.03) 0.13 0.17 1.29 1.09–1.53 .003Level 4 0.014 (� 0.03) 0.01 0.01 1.06 0.52–2.19 .868Total incidents 0.91 1.18 1.29 1.13–1.49 < .001

aSee Methodology section for descriptions of the level of severity of verbal or physical aggression. bRate of aggressive incidents per 100 patient bed-daysfor each type and level of aggression measured by the Overt Aggression Scale across the study units. Data calculated from the average of the number ofaggressive incidents per patient bed-day for each month from January 1996 to October 2005. cMeans within each type of aggression (verbal or physicalaggression against others) with different superscripts (1, 2, 3 or 4) that differ significantly (p < .001). dRelative risk = Probability of females beingaggressive/probability of males being aggressive. ep Value = chi-squared value for relative risk using robust error variances.



of verbal aggression at Level 1 (makes loud noises, i.e., shoutsangrily) and Level 2 (yells mild personal insults). Conversely,the average number of incidents per 100 bed-days per monthof physical aggression against others at Level 1 (makes threat-ening gestures, swings at people, grabs clothing) and Level 2(strikes, kicks, pushes, pulls hair without injury to person)was significantly (p < .01) higher than the average number ofincidents of physical aggression against others at Level 3(attacks others causing mild/moderate physical injury—bruises, sprains, welts) and Level 4 (Attacks others causingsevere physical injury—broken bones, deep lacerations, inter-nal injury).

Verbal aggression at Level 1 was less likely to be reported forfemale patients versus male. Conversely, verbal aggression atLevels 2, 3, and 4 were more likely to be reported for femalesthan for males (see Table 2). Physical aggression againstothers at Levels 1, 2, and 3 also was more likely to be reportedfor females than for males, while physical aggression at Level 4was equally likely for both.

When reported on the same OAS form, the severity ofverbal aggression was not significantly (r (4,826) = -0.003, p =.828) correlated with the severity of physical aggressionagainst others. When reported for each gender, the severity ofverbal aggression was significantly negatively related to that ofphysical aggression against others for female patients (r(2,007) = -0.097, p < .001) but not for male patients (r (2,817)= 0.034, p = .07).

Aggression and Diagnosis

The total number of reported incidents of verbal aggression(incidents/year) was significantly (p < .001) greater whenpatients were diagnosed with psychosis (M = 101.78, SEM =3.37) compared with any other disorder. The total number ofincidents of verbal aggression at Levels 1, 2, 3, or 4 was signifi-cantly higher when patients were diagnosed with psychosisthan for those diagnosed with either major depressive disor-der (MDD) or BAD (see Table 2).

The number of reported incidents of verbal aggression orphysical aggression against others was significantly higherwhen the perceived cause of aggression was psychosis (p <.001) compared with any other cause. The perceived motiva-

tion for verbal aggression was not significantly different formales and females when the motivation for aggression wasmaterial gain (p = .545),provocation (p = .060),or self-defense(p = .381). The total number of incidents (incidents/year) ofverbalaggressionatany levelwassignificantly (p< .001)higherwhen the perceived motivation for aggression was internal (M= 55.2, SEM = 3.0) versus external (M = 6.9, SEM = 3.1). Thetotal number of incidents of verbal aggression at any level wasalso significantly (p < .001) higher when the perceived motiva-tion was internal compared with external.

A total of 1,829 comments regarding perceptions of moti-vation for patient aggression were also recorded by staff onthe OAS. The main perceived causes for aggression wereorganic brain damage (27.3%), other patients and the wardenvironment (10.2%), aggression in response to nursing orother staff intervention (9.8%), and aggression resulting fromthe patient’s personality or long-standing traits (7.6%).

Interventions Following an Episode of Verbal or PhysicalAggression

Nurses recorded on average 1.9 interventions per incident ofaggression, indicating that more than one intervention wasfrequently specified for each incident of aggression. The mostfrequently reported interventions for incidents of verbalaggression were talking to the patient (70% of incidents),increasing the level of observation (40%), use of oral medica-tion (25%), and seclusion and segregation (20%). Talking tothe patient was most frequently used for verbal aggression atLevel 3 or 4. Less frequently cited methods used across alllevels of aggression included increased degrees of observa-tion, oral medication, and seclusion.

A total of 1,275 comments regarding interventions forverbal aggression were recorded on the OAS. The most fre-quently recorded interventions for aggression were separa-tion from other patients (27.2% of incidents), use ofmedication (6.9%), and walking (6.0%). Staff reported 94interventions specifically for swearing; the most frequentlyrecorded interventions were ignoring the behavior (31.2% ofincidents of swearing), attempting to placate the swearer(22.6%), withdrawing from the patient (18.3%), or confront-ing the behavior and taking assertive action (12.9%).

Table 2. Number of Incidents of Verbal or Physical Aggression per Year for Selected Diagnoses as Reported by the Overt Aggression Scale from 1996to 2005

Diagnosisa p Values

Psychosis MDD BAD Diagnosis Levelc Diagnosis ¥ Level

Verbal 101.781 (� 3.37) 0.532 (� 3.37) 7.532 (� 3.37) < .001 < .001 < .001Physicalb 73.701 (� 2.69) 0.802 (� 2.69) 6.252 (� 2.69) < .001 < .001 < .001

Note. Values are least squares means � standard error of the least squares means. aMeans in each row with different superscripts (1 or 2) differ signifi-cantly (p < .01). bPhysical = physical aggression against others. cLevel = level of severity of aggression. BAD, bipolar affective disorder; MDD, major depres-sive disorder.



The Association Between Diagnosis and Intervention forAggression

The interventions used by staff for verbal aggression or physi-cal aggression against others at any level were not significantly(p > .05) different when patient diagnosis was psychosis, BAD,or MDD. However, as the severity of verbal aggression bypatients diagnosed with psychosis increased from Level 2 toLevel 4, the intervention was significantly (p < .05) more con-trolling. Similarly, as the severity of physical aggressionagainst others by patients diagnosed with either psychosis orMDD increased from Level 2 to Level 4, the intervention wasalso significantly (p < .05) more controlling. When the per-ceived motivation for any level of verbal aggression was inter-nal, the intervention was significantly (p < .001) morecontrolling. Conversely, when the motivation for aggressionwas external, interventions used were more noncontrolling.

Exposure of Nurses to Swearing

Nurses who completed the NSIQ reported being exposed to ahigh frequency of swearing, with 29% of respondents report-ing being sworn at 1–5 times per week and 7% reportingbeing sworn at continuously. The reported frequency ofexposure to swearing was not significantly (p < .05) differentfor nurses in mental health versus pediatric settings. Themajority reported that exposure to swearing was highly dis-tressing, with 50% indicating that their distress from expo-sure to swearing in any of the six hypothesized situationsidentified in the NSIQ was a maximum of 5 out of 5. Nursesreported higher levels of distress from exposure to swearingfrom patients’ families, compared with swearing associatedwith “threats,” “physical aggression,” or “personally demean-ing comments” (see Figure 1). Females appeared to be very

distressed irrespective of the situation, whereas malesreported being significantly more distressed by relatives ofpatients swearing at them (see Figure 1).

The category of words nurses found most offensive couldbe described as “sexual/excretory words,” and nurses ratedwords used largely for emphasis as less offensive. It is likelythat nurses in other countries may order offensiveness differ-ently, but the rating of sexual/excretory words as most offen-sive is consistent with the literature on offensiveness.

In contrast to minimal differences in the frequency ofexposure to swearing between pediatric and mental healthsettings, the reported distress level from exposure to anyswearing was significantly higher for pediatric nurses (M =3.65, SD = 0.37) than mental health nurses (M = 2.98, SD =0.98) (t (104) = 2.77, p = .007). The reported distress levelfrom exposure to swearing was significantly higher for femalenurses than male nurses (Stone, 2009).

NSIQ respondents were asked to “briefly outline the mostdistressing experience you have had when a patient or carerswore at you” in a Situation, Action, and Outcome format. Ofthe 100 incidents provided, the swearer was identified in 94:72 (76%) of these incidents involved patients, 10 (11%) rela-tives or carers, and 12 (13%) a staff member. The age of theperson swearing was recorded in 92 instances, the personswearing most likely to be 18 years old or older (66%) com-pared with under 18 (34%). The gender of the person swear-ing recorded in 93 instances was more likely to be male (56%)than female (44%).

Discussion

Data from the OAS indicated that verbal aggression was themost frequently recorded type of aggression in the mentalhealth units included in this study. This is consistent with pre-

Figure 1. Wounding Words:Swearing and Verbal Aggression inan Inpatient SettingMean distress scores reported by nurseson the Nursing Swearing ImpactQuestionnaire (NSIQ) for exposure to“swearing in a work situationassociated with” (a) threats, (b) physicalaggression, (c) personally demeaningcomments, or (d) “being sworn at”repeatedly, (e) by patients’ relatives orcarers, or (f) by another staff member



vious studies from acute care mental health settings interna-tionally (Daffern et al., 2006; Foster, Bowers, & Nijman, 2007;Owen, Tarantello, Jones, & Tennant, 1998a; Owen et al.,1998b).

Verbal aggression at any level was more likely to bereported for male than female patients; however, more severeverbal aggression was likely to be reported for females thanmales. The over-representation of female verbal aggression athigher levels may be caused by stereotypic gender bias leadingto underestimation of aggression at low levels and inability torecognize and respond to nonverbal cues that may be indica-tive of escalating the severity of behavior (Robinson, Littrell,& Littrell, 1999). When verbal aggression and physical aggres-sion against others at the same time were reported for femalepatients, the severity of verbal aggression was negativelyrelated to the severity of physical aggression, indicating thatfemale patients were less likely to be verbally aggressive as theseverity of physical aggression increased. This was not thecase for male patients, a distinction that may be important inteaching nurses how to recognize and prevent more seriousaggression, as well as alerting them to the fact that male andfemale patterns of aggression may differ.

Concerning the relationship between patient illness andaggression, patients with psychosis and BAD were more likelyto be responsible for aggressive incidents than patients withMDD. Patients with psychosis were more likely, also, to be ver-bally, rather than physically, aggressive, which is consistentwith previous research by Barlow et al. (2000). The findingthat patients diagnosed with psychosis were associated with ahigher number of instances of aggression links with the per-ceived motivations for aggression recorded by nurses.

Verbal aggression was most likely to be attributed by nursesto factors intrinsic to the patient (Duxbury, 2002), includinggender, diagnosis, and substance use. Comments recorded onboth the OAS and the NSIQ indicated that external factorsand interactions between internal and external factors (thesituational model) were less likely to be reported as the moti-vation for verbal aggression. Hahn, Needham, Abderhalden,Duxbury, and Halfens (2006) proposed that the attribution ofmotivation to the internal model may be derived from thebiomedical model, which provides justification for the use ofmedical treatment for aggression, or a defense mechanism toabsolve nurses with poor communication skills from per-sonal involvement and accountability. The “fundamentalattribution error”(Jones & Nisbett, 1971) suggests a universaltendency to attribute the cause of the actions of someone else(but not their own actions) to the internal disposition of theperson, particularly in circumstances where the motivation isambiguous. When NSIQ nurses were asked to consider inmore detail aggressive incidents, particularly swearing, theyappeared to show greater understanding of contextual factorssuch as the dynamics between themselves, the environment,and the patient.

Interventions for Aggression

A limited range of interventions was used to deal with inci-dents of aggression. Talking was recorded as the major inter-vention, used in approximately 70% of incidents of verbalaggression at all levels, frequently combined with anothermore controlling method; the form this “talking” took is notspecified. Less frequently cited methods used across all levelsof aggression included increased level of observation, oralmedication, and seclusion. Differences between nonauthori-tarian therapeutic interactions and more directive communi-cation would give an important insight into the way in whichnurses deal with verbal aggression. Of particular importanceis the finding of increased use of controlling interventions asthe severity of verbal aggression increased from Level 1 to 4for patients diagnosed with psychosis or MDD. Data from theOAS indicating that controlling interventions such as isola-tion, mechanical restraint, and medication were used whenthe perceived motivation for aggression was internal com-pared with external, also agree with the framework proposedby Duxbury (2002). It is possible that only the most seriousinstances of aggression were recorded, and aggression result-ing from external circumstances may have been underre-ported or prevented. The interventions used may reflect onlythe degree of severity of aggression reported; however, thesefindings appear to conflict with recommendations thatproblem solving and de-escalation should be first-choiceinterventions to deal with aggression and restraint, and seclu-sion measures should be a last resort (Cowin et al., 2003).

Implications for Nursing Practice

Findings from the present study indicate that nurses per-ceived the cause of most aggressive instances to be factorsintrinsic to the patient. Nurses appear, when asked to consideran incident in more detail, to have appreciated the role ofdynamics between the environment and the patient; however,the limited range of interventions used to deal with thebehavior was still evident. Means must be found to allownurses to spend more time investigating and reflecting on thecauses of aggression in their work setting in order to deter-mine whether the responses to the aggression were appropri-ate or if alternate methods should be employed.

Data indicate that as the severity of physical aggressionincreased, the severity of verbal aggression decreased forfemale but not male patients. These findings do not accordwith conventional wisdom, which suggests that verbal aggres-sion generally precedes physical aggression, as Felson andSteadman (1983) found in their study on criminal violence.This learning should be incorporated into training programsto teach nurses how to identify escalating patterns of aggres-sion and then employ strategies to de-escalate it before theseverity increases to an unmanageable level.



It is perhaps surprising that pediatric nurses’ experiencesof swearing, and the frequency of their exposure to it, do notdiffer markedly from those of their mental health colleagues;though pediatric nurses reported more distress than didmental health nurses. Context is likely to be a major factor:Boundary-crossing and taboo-violating behavior such asbeing sworn at in front of young children and their parentsmight conceivably be more confronting than being sworn atin a mental health unit, where there are fewer visitors and themain audience comprises other patients and staff.

Given the frequency of occurrence of swearing and verbalaggression, and the distress caused, methods need to be foundto improve nurses’ response in order to reduce the distress.Greatly needed is a better understanding of what is occurringin these interactions, and what nurses mean when they saythey talked to the patients. Careful consideration is requiredregarding how we should respond to build therapeuticengagement: An element would be helping nurses to developmore effective “distress tolerance skills,” modeled perhaps onthose skills known to be effective in assisting clients tomanage distress associated with conditions such as borderlinepersonality disorder. Strategies like those used in DialecticalBehavior Therapy (DBT) could be taught to nurses, as theyare to therapists (some of whom are nurses), who employsuch techniques. Another possibility would be to revisit indi-vidual and group forms of clinical supervision, with specificfocus on working through distress, and devising ways ofcoping more effectively in conditions where nurses are likelyto be exposed to swearing and verbal aggression; it could bethought of as a kind of “therapy for the therapists,” again fol-lowing a DBT model.

Although nurses were surveyed on swear words frequentlyused in Australia, the only uniquely Australian swearwordused was “fuckwit.” The words found to be most offensive,“cunt,”“cocksucker,” and “mother fucker,” are swear words inother English-speaking countries. The category of wordsnurses found most offensive could be described as “sexual/excretory words,” and they rated words used largely foremphasis such as“damn,”“crap,”and“hell”as less offensive. Itis likely that nurses in other countries may order offensivenessdifferently, but the rating of sexual/excretory words as mostoffensive is consistent with the literature on offensiveness.

Limitations

Data from the OAS, in the current study, were collected from alarger number of reports over a longer timeframe (10 years)than those reported overseas;however,OAS reports were com-pleted for only 533 patients, averaging 18 incidents for eachpatient, which provides a potential for bias toward certaintypes of aggression.Problems are associated with the measure-ment of verbal and physical aggressions in psychiatricunits because many factors—personal, interpersonal, and

cultural—influencethedegreetowhichincidentsarerecorded(Edwards & Reid, 1983). Despite the large OAS sample size inthe current study, there may have been systematic underre-porting. While all instances of aggression may be underre-ported (Farrell,Bobrowski,& Bobrowski,2006; Holmes,2006;Mayhew, 2000), less severe instances of aggression may beunderreported to a greater extent than more severe instances.

Staff may have not reported a particular instance of aggres-sion for a number of reasons, including having developed ahigh threshold for verbal aggression. Particular diagnosesmay have been overrepresented in the sample, as the base ratesof each diagnosis for the entire inpatient population were notestimated and controlled. However, the reporting of psycho-sis as the main motivation for aggressive instances agrees withfindings that the majority of aggressive instances involvedpatients with a diagnosis of psychosis.

A lack of anonymity with OAS reporting may have also ledto a tendency to report aggression in ways thought to beacceptable to the supervisor, or may have reflected what staffthought should have happened rather than what actuallyoccurred. Staff also may not have felt free to identify shortfallsin the management of aggression, including the possibility ofpreventing aggression, because of potential negative reper-cussions.

Accurate records of the frequency of swearing are notori-ously hard to achieve (Jay, 1992), and the NSIQ study was noexception; when asked to report the number of incidentsexperienced during the last week, nurses in many cases foundit difficult to quantify because its frequency made keepingcount impossible.

Conclusion

Data from the current study indicate that nurses are regularlyexposed to swearing in Australian mental health settings andthat exposure to swearing is often associated with verbalaggression. Swearing is clearly a major source of distress fornurses; the strong affective responses reported by manyrespondents have implications for the establishment andmaintenance of a therapeutic relationship in that they colorthe interactions nurses have with patients.

The underlying philosophy behind the preponderance ofthe internal model of causation, in which nurses attributeaggression to the patient’s inherent characteristics, centers onthe biomedical model, which provides a justification for theuse of medical treatment for aggression as well as freeing thenurse from individual responsibility for examining his/herown behaviors (Hahn et al., 2006). The range of therapeuticinterventions was limited. This tends to conflict with the rec-ommendation that when dealing with aggression problemsolving, de-escalation should be the first choice of interven-tion, with restraint and seclusion measures as last resort.While nurses could identify relationships between internal



and external motivations for patients’ aggression, moreresearch is needed to clarify the types of interventions used bynurses, particularly when the reported intervention is“talkingto the patient.” The clarification of the responses to swearingand verbal aggression and the types of interventions used maylead to optimal outcomes for patients and reduced distressexperienced by nurses in response to this aggression.

The exploration of the impact on nurses as a result ofverbal aggression and verbal aggression’s effects on the thera-peutic relationship have produced findings of value inimproving nurses’ abilities to predict and perhaps preventaggression. Connections have been established between theirattributions about the cause of aggression and the interven-tions employed. Care must be taken in interpreting these data:It is likely that only the most serious incidents of aggressionhave been recorded, and interventions therefore reflect thedegree of severity.

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wounding words: swearing and verbal aggression in an inpatient setting

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