Violence in the Emergency Department - Health Care Workers - Research Paper Example

A Quantitative Research Study Critique: Violence in the Emergency Department: A Survey of Health Care Workers A Quantitative Research Study Critique The research study by Fernandes, Bouthillette, Raboud, Bullock, Moore, Christenson, Grafstein, Rae, Ouellet, Gillrie, and Way (1999) was a means of exposing the violence happening in emergency departments. The research study was a method of bringing awareness to the frequency of such behavior occurring and the types of violent behavior perpetrated against medical professionals. The primary objectives noted by Fernandes et al (1999) were to 1) examine perceived levels of violence; 2) obtain the definition of violence from emergency department workers; 3) determine the effects of violence on workers; and 4) determine potential preventive strategies. Through the selection of supporting literary research studies, analysis/interpretation of data and observations the objectives of the study were accomplished. The purpose of this paper is to critically reviewing the format, content in relation to the objectives, and evaluate the effectiveness of the quantitative research study. Abstract The scientific style of writing is a formal and rigid form of writing which is to succinctly with efficiency communicate scientific findings (Bates College, 2011). The abstract section of a research study should announce what is to proceed and clearly state the research question(s) or problem(s) under investigation. Additionally as the introduction the abstract should contain a descriptive of the research design, methodology used in the study, primary results or findings. along with an abbreviated analysis of the results in relation to the research study’s objectives. As a scientific research study the abstract should spark the curiosity in others and offer additional knowledge on the subject motivating and stimulating interest in the minds of the readers enticing him or her to continue reading with interest and anticipation. Creswell (2008) in his instructions on how to write compelling research studies suggested using crisp, clear, concise verbs and descriptive language incorporating the strategy used for data collection, identifying the research site, and providing information on the participants in the study as an interlude or in the abstract of the study (pp. 113-119). Neuman (2006) emphasizes the mental or critical thinking component of the researcher(s) as the initial undertaking with the evolution of the study taking form after the thought process is engaged and the decision of what the purpose and objective of the study is about and hopes to accomplish. Neuman (2006) suggested in his methods of formulating an effective, concise, informative report taking the time to thoroughly think through the process of writing and formulating the objective(s) of a study as a means of preparation. The abstract section of the paper was vague and lacked specificity and did not state the research design or the methodology (Christensen, Johnson, & Turner, 2011; Creswell, 2005; Neuman, 2006). The purpose of the study was underdeveloped. To create a more compelling abstract, one suggestion is to re-organize the format of the paper more succinctly and re-write the abstract following the development and completion of the paper in its entirety using definitive and descriptive verbs and nouns to capture the interest of the reader. Research Problem The subject research study identified the central issue under investigation in the study as the occurrence of violence against medical personnel in emergency department(s). The purpose of the study was to bring awareness to the extenuating and potentially life threatening conditions medical personnel are subjected to in performing their professional duties. Whereas the primary focus of the study were the events occurring at one specific hospital the explicit inference alluded to acts of violence against emergency department workers as commonplace in the profession and one in which is escalating in frequency. Creswell (2005) asserts the research problem or question(s) narrows the scope of the study and clarifies the direction of the investigation (p. 117). Christensen, Johnson, and Turner (2011) stated a, “Research problem is an interrogative sentence that states the relationship between two variables” (p. 87). The subject study did not ask a specific research question as to why the phenomenon is happening or pose suggestions as to how the events could be curtailed or controlled, but in essence presented various charts and graphs to substantiate the occurrences. Undoubtedly, the phenomenon is cause for concern not merely from the standpoint of the physical harm that jeopardizes the safety of workers in the emergency department, but additionally against innocent persons present during the violent outbursts and eruptions. The burden emergency department workers have of providing critical care, and managing the emotional component that accompanies the events that brings individuals to an emergency department in a metropolitan city in and of itself is a tremendous responsibility. The phenomenon of violent acts occurring in the emergency department is now requiring medical professionals to function defensively in response to the potentially life threatening confrontations while simultaneously performing his or her professional duties. In relation to the problem, one significance factor affecting those in the nursing profession is the concern for safety in the workplace in hospitals. The complexity of the field of nursing is multiplied in the emergency department due to the characteristics of the internal environment of the department. The ability to manage and administer critical and acute care, organize and initiate administrative and medical procedures simultaneously at times, and to interact compassionately with individuals experiencing a traumatic event are only a few of the obligations of the nursing profession. In the emergency department the innate characteristics and traits of the internal environment are amplified because of the nature of the conditions and circumstances that exists. The presence of violence whether perpetrated against personnel or occurrences stemming from domestic violence, abuse, or addiction only accentuates the difficulty of performing the needed services when the threat of violence is present. Christensen et al (2011) stated a “Hypothesis is the best prediction or a tentative solution to a problem” (p. 89). Fernandes et al (1999) explicitly suggested that safety procedures and precautious be a means of controlling or managing the violent behavior in the emergency department. However, by implicitly offering suggestions as to specific measures and operational practices to implement into the department would present a more convincing and stronger perspective in the study. The format of the study merely was to inform and disclose the phenomenon through the use of charts of events and graphs, but did not offer applicable solutions. In descriptive quantitative research determining the relationship between two variables is one of the underlying objectives as opposed to establishing causality (Leedy & Ormrod, 2010, pp. 224-225: Christensen, Johnson & Turner, 2011). Leedy and Ormrod (2010) stated, “A variable is any quality or characteristic in a research investigation that has two or more values” (pp. 224-225). Determining the relationship between the phenomenon and the corresponding outcome is one observation in the subject study, opposed to determining causality the cause (independent variable) and effect (dependent variable) (Leedy & Ormrod, 2010, pp. 224-225). Embedded in the research study the sporadic, unpredictable, and frequently occurring violent behavior presents the independent variable. Creswell (2005) says “An independent variable is a characteristic or attribute of an individual or an organization that (1) researchers can measure or observe and (2) varies among individuals or organizations” (pp. 118-119). His definition identifies the violent behavior as the observable phenomenon. Theoretical Framework Christensen et al, (2011) suggested a good theory suggest new relationships and links between variables functioning as a catalyst for new researchable ideas (p. 71). Using the explanation of Marx (1963) a theory has two functions 1) as a goal, and 2) a tool. The goal component summarizes and integrates existing knowledge; the tool component guides the research (as quoted in Christensen et al, 2011, pp. 71-72). Fernandes, et al (1999) did not present a theory in the research study, but more or less presented evidence of the phenomenon of violence in the emergency department occurring. Literature Review The footnote style of writing of the literature review of supporting studies interrupted the cohesion of the paper and did not allow for smooth reading and comprehension of the rationale for the study (Fernandes et al, 1999). However, the articles and studies presented adequately described the occurrence of the phenomenon and helped confirm the feasibility for the research project. Leedy and Ormrod (2010) assert the literature review is a process of analyzing previous studies on a subject to gain insight into the problem or phenomenon from varying perspectives of other writers. As such the literature review is a method in which a researcher(s) is able to solidify his or her rationale for undertaking a study and substantiates the reasons for the project based on the additional evidence gleaned from reviewing other writers’ perspectives on the subject. The process helps to clarify and formulate a plan of action as to how to approach the problem under investigation using the information from other studies as a foundation from which to proceed and build. Fernandes et al (1999) did include and note the lack of investigation into the phenomenon of violence in the emergency department in medical facilities and the effects the events have on worker performance and operational procedures. The majority of the articles reviewed only confirmed the occurrence of the events and noted the absence of research into the phenomenon. However what was glaringly absent in the selection of supporting articles on the subject were suggestions of practical, workable solutions, and applications in which the departments and organizations could implement. Notably, Fernandes et al (1999) and several of the authors in the supporting articles sporadically mentioned the need for more effective and efficient safety precautions and measures for medical workers in the emergency department but did not develop the concept. The omission of possible solutions addressing the phenomenon was the primary gap in the literature presented. The footnote style of formatting of the literature review caused confusion during reading. In analyzing and evaluating the organization, cohesion, and the logical flow of the literature the format was jumbled and out of sequence with the organizational structure of the subject study. The literature reviewed was appropriate contributing to the increased comprehension of the problem, but was bias in that it only depicted one perspective and did not include medical facilities that are using safety measures to reduce and eliminate violence from happening in the emergency department. Legal and Ethical Issues Research Approach Creswell (2005) cites the research approach is a method of identifying a problem developing a strategy of how to study the subject, what data collection method(s) to use, and means to analyze and interpret the data (pp. 44-51). Fernandes et al (1999) suggested in the title of the study that a quantitative research approach was used in the investigation. Quantitative research is an analysis and interpretation of statistical data to make inferences as to relationship between variables (Creswell, 2005, p. 39, Christensen, et al, 2011, pp. 29-30 ). However upon reading the study the data collection methods suggested a mixed method research study approach evolved during the process of completing the study. The choice of a quantitative research approach was inadequate and insufficient to present the information, but a mixed method approach, the combining of qualitative and quantitative techniques and methods was more suitable for conducting a thorough investigation of the phenomenon. Because human behavior cannot be quantified or examined by using numerical data implementing the practices of qualitative research methods enabled the researchers to produce a comprehensive study of the phenomenon. . Design: From the standpoint of the initial intent of the writers and the research problem under investigation, a quantitative design appeared to be adequate to present the data; but the inclusion of the verbal accounts and data collected from workers with firsthand knowledge and experience altered the design (Christensen, et al, 2011, pp. 29-30). A mixed method design approach combines the suitable characteristics of the qualitative and quantitative research approaches enabling researchers to explore a subject more thoroughly and to understand the complexity of human interaction and behavior easier. Sample and Population: The population from which the sample was taken was an inner-city metropolitan hospital in Vancouver (Fernandes et al, 1999). The writers’ chose a sample from a group of workers in which he or she had either been a victim of the violence or witnessed violent behavior perpetrated against other co-workers in the emergency department. The primary demographic criteria of the participants were: 1) personal definition of violence; 2) severity of violence witnessed; 3) personal estimation of the degree of stress as a result of the encounters; and 4) an estimation of the number of violent events witnessed in the emergency department (Fernandes et al, 1999). Because the researchers were specifically observing the eruptions of violence in one hospital, the findings cannot be reproduced or replicated by others with an interest in the social phenomenon. In social research studies the use of either the random sample or non-random sample techniques is common. In the case presented by Fernandes et al (1999) the non-random sampling method was used. Christensen et al (2011) refer to a non-random sample as a “biased sample” because the data collected is not representative of the whole population (pp. 152-159). The selection method for the participants is suspect as well due to the criteria for those participating in the study to substantiate the evidence of violence occurring in the emergency department. Internal and External Validity: The internal validity on one hand is valid, the researchers’ objectives were substantiated by the results of the data collected. Overall, however the integrity of the research is invalid because if similar studies were performed using a more inclusive or random sampling of emergency department workers the result would be different. Research validity is the truthfulness of the inference or interpretation of the results of the study (Christensen et al, 2011, pp. 168-170). Even though the results verified the evidence of violence in the emergency department because of the subjectivity and bias of the researchers the integrity of the results is diminished. Methods: Internal validity is the inference of a relationship between two variables (Cook & Campbell, 1979, p. 37 as quoted in Christensen, et al 2011, p. 176). External validity on the other hand is the degree to which a study’s results can be generalized to and across other people, settings, treatments, outcomes, and times (Christensen, 2011, p. 186). In analyzing the application of the two descriptions of what internal and external validity are to the subject of violence in the emergency department is cause for contemplation. The demonstration of the relationship of the independent and dependent variables is questionable in a sense because the behavior is uncontrollable and in some cases is unpredictable. The skepticism arises from circumstances in the emergency department that may or may not cause the explosion of violent behavior but could conceivably be curtailed through the use of intervention and preventive measures. A measured threat to the internal validity in the subject study is that of extraneous variables, variables that researchers cannot predict or control (Christensen, 2011, pp. 177-197). Managing to maintain the influences of extraneous variables keeping them constant is the objective, but because of the unpredictability of human behavior the unknown and influencing factors motivating or stimulating the exhibition of violent behavior cannot be contained. As a means of control for the threats to internal validity implementing safety features to detect the possible occurrence of violent behavior would be one way of controlling the threats. Monitoring such behavior as individuals appearing under the influence of alcohol or drugs, or exhibiting erratic or pronounced physical motion such as slurred speech, staggering, or halting steps would help to reduce the threats to the internal validity. On the other hand, controls of the threats to external validity is quite another matter. The most prominent threat is that of replication and reproducibility. Because external validity pertains to the ability to generalize the research findings the subject study is marginalized. External threats to validity are grouped into five categories: population validity, ecological validity, treatment variation validity, outcome validity, and time validity (Bracht & Glass, 1968; Shadish, Cook & Campbell, 2002; Wilson, 1981 as quoted in Christensen et al, 2011, pp. 186-190). As indicated in the opening statement the quantitative design technique of using surveys was the method to collect data from the sample population. Theoretically the sample was bias because of the exclusion of a random sample, however the researchers did not disclose the constraints or reasons for confining the research study to the specific group. Reliability and Validity of Instruments Types of Tests From all indications the researchers did not include reliability tests for the data collection instruments used in the study. In general the description of the methods of data collections used in the study were the primary focus. Whether or not the researchers took into account the possible percentages of fabrication and exaggeration present in the re-counts by workers is unknown as well. Undoubtedly the study contains reliability gaps and the scientific testing of how the interpretation of the data was done is lacking as well. The absence of the pertinent data as to how the researchers arrived at their findings from the data creates a condition in which the creditability and reliability of the data is questionable. The absence of the statistical tables as to how the data was analyzed resulting in the findings reveals another inconsistency in the research structure and design. By providing the verification of the numerical data substantiates the findings and lends creditability to the report. The researchers included percentages and averages as statistical data pointing out the obvious relationships between violence in the emergency department(s) and medical workers which underscores the study’s objectives; but the study did not contain enough information about the mechanics of how the data collected from the surveys was translated into statistical data enabling the formation of inferences as to the reasons for the violent eruptions. Leedy and Ormrod (2010) stated, “Statistics have two principal functions: to help the researcher (1) describe the data and (2) draw inferences from the data. Descriptive statistics summarize the general nature of the data obtained and inferential statistics help the researcher make decisions about the data “ (pp. 30-31). The descriptive statistics in the study were represented by the types of violent behavior exhibited and the effects the violence had on the workers as a result. The description of the reactions of the workers during and after a violence event was useful in supporting the objectives. The inferential statistics in the report were the interpretations of the violent acts, inferences made to explain the causes and reasons for happening. The observations of the violence and its effects is what was conveyed in the report, however in citing the events and outcomes the researchers noted the possible relationships inferring the significance in understanding the phenomenon. The statistics in the study support the objectives and to a certain degree the tables included pictorially document the events and effects. The tables were thought to clarify the statistical data, but only prove to further complicate the issues and create more unanswered questions. The charts and tables visually reflect the types of events, frequency, aftermath, and escalation nature of the events but in the abstract format are disruptive to the general reading and flow of the report. The report did not include any further hypothesis testing performed to substantiate the findings and one limitation in the report is the selected group of workers which reflects bias or manipulation on the part of the researchers. Notably the relevance to the nursing practice is the need for those entering the profession to be cognizant of the potential threats of violence that occurs in the emergency department and to acquire defensive mechanisms for possible future events involving violence. No specific mechanisms were proposed other than awareness and operational procedures to lessen the effects and prevent further injuries from happening. The recommendations for future studies evolved around more of the same types of analysis in which the effects on workers is at the forefront. The research study did not propose possible future research studies in which solutions or preventive measures to circumvent the events should be investigated. Understandably attempting to predict the future is irrational but observing emergency department visitors would be the initial starting point for developing measures to lessen the effects and possible circumvent the events from occurring. Analysis of Data The strengths of the study are that the researchers corroborated their premises with the studies of other researchers confirming the results of violence in the emergency department as a growing and understudied social phenomenon. The sampling provided support for the premise that the eruption of violence has devastating effects on the workers that potentially can interfere and jeopardize the safety and well-being of by-standers in the emergency department. On the other hand the weaknesses of the study are that it failed to follow the format for scientific writing, omitted sections of supporting evidence of the phenomenon such as the literature review, and the sampling method was biased with the selection of certain workers and was not representative of the entire population of workers in emergency departments in general. Analyzing the research study the strengths and weaknesses are equal in their contribution to the validity of the study. The writers were effective and accomplished their objectives of bringing awareness to the social phenomenon and its effects on workers in the emergency department. However, using a more objective perspective in presenting the evidence to support the premises of the study would have validated the findings. By using a non-random sample from a specific hospital did not lend creditability to the inferences and interpretation of the research findings. Taking an objective position and including survey results from the general population over a wider geographical and demographic spectrum would more than likely result in varying outcomes. Raising the level of awareness of the conditions and circumstances occurring in emergency department(s) is the prominent benefit of the study. A general assumption is inferred in the study that the conditions are widespread throughout the medical community and the data from the workers at the Vancouver medical facility are representative of the general climate and conditions in a significant number of emergency departments. A risk to implementing the practices of the study would be that the results would be slanted and unable to be verified as factual in all medical facilities. One recommendation for the study to significantly contribute to the growing knowledge base on violence in emergency departments is to formulate a better constructed study using a random sample. Looking at the phenomenon from an aerial view encompassing an entire community or city would stimulate interest and possibly be the catalyst of change to create internal procedures in emergency departments that would protect workers as well as safeguard innocent by-standers and perpetrators as well. Conclusion Conclusions, Recommendations, and Implications: Even though the study lacked pertinent components to substantiate the current and growing concern regarding emergency department workers the objective of bringing awareness to the topic was accomplished. The recommendations for further investigations into the phenomenon were to continue looking at the behavior from a defensive perspective namely the effects of the behavior on workers. Taking an offensive posture could produce strategies to reduce the types and frequency of violent outbursts in the emergency departments and possibly prevent such behavior entirely if analyzed from a new perspective. Application & Utilization for Nursing Practice: The application of the knowledge conveyed in the research study for the nursing profession is that the responsibilities of the industry are demanding requiring a commitment in which staying abreast of what occurs in the working environment is a factor. Using education as a measure or a supplement to the technical training could be an asset to those entering the profession. An ongoing educational awareness training program highlighting the occurrences of the phenomenon in the workplace is one method of raising the level of awareness and curtailing the events from happening. Another method is self-defense courses in which nurses and emergency department workers are equipped with means to protect themselves from physical assaults and potentially prevent the injury to other visitors to the department. As the complexity of living in the 21st Century increases and the diversity and density of the socioeconomic groups continue to evolve the subject of human behavior is an ongoing dialogue. Understanding and interpreting observable human behavior gives social scientists a mere glimpse into the hidden or underlying motivations that prompts certain behaviors of which the disturbances of violence in emergency departments is one. The continuation of research into the phenomenon can only contribute valuable knowledge to the growing base of research investigation and potentially change the way medical professions interact with patients and how medical facilities develop safety strategies as intervening counter measures. References Bates College. (2011) The structure, format, content, and style of a journal-style scientific Paper. Retrieved from http://abacus.bates.edu/~ganderso/biology/resources/writing/HTWsections.html#abstract. Bracht, G. H., & Glass, G. V. (1968). The external validity of experiments. American Educational Research Journal, 5, 437–474. Christensen, L. B., Johnson, R. B. & Turner, L. (2011) Research methods, design, and analysis, (11th Ed.). Boston, MA: Pearson Education/Allyn and Bacon. Cook, T. D., & Campbell, D. T. (1979). Quasi-experimentation: Design and analysis for field settings. Chicago, Il: Rand McNally. Creswell, J. W. (2005). Educational research: Planning, conducting, and evaluating quantitative and qualitative research, (2nd Ed.). Pearson Education, Inc/ Merrill Prentice-Hall. Creswell, J. W. (2008). Research design: Quantitative, qualitative, and mixed methods approaches. Thousand Oaks, CA: Sage Publication. Fernandes, C. M.B., Bouthillette, F., Raboud J. M., Bullock, L., Moore, C.F., Christenson, J.M., Grafstein, E., Rae, S., Ouellet, L., Gillrie, C., & Way, M. (1999). Violence in the emergency department: A survey of health care workers. Canadian Medical Association Journal (CMAJ), 161(10), 1245-48. Retrieved from http://canadianmedicaljournal.ca/content/161/10/1245.full. Marx, M. H. (1963). Theories in contemporary psychology. New York, NY: Macmillan. Neuman, L. (2006). Social research methods: Qualitative and quantitative approaches, (6th Ed.). Boston, MA: Pearson Education, Inc/Allyn and Bacon. Shadish, W. R., Cook, T. D., & Campbell, D. T. (2002). Experimental and quasi-experimental designs for generalized causal inference. Boston, MA: Houghton Mifflin Wilson, V. L. (1981). Time and the external validity of experiments. Evaluation and Program Planning, 4, 229–238. Read More