Violence and Aggression in the Health Care Sector

When considering mechanisms affecting this level, there are two factors that are important and that can be controlled by will. This level focuses on decreased self-control and non-professional communication.These two factors can cause escalation into violence due to strengthening of aversive impulses. There is a very close link between self-control and communication. 

When a person’s interests, safety or values are endangered, the cortex, thalamus and amygdala trigger an anti-stress program that enables people to save their interests, values and safety by means of an escape or an attack. People react then with anger, aggression or anxiety to deal with an unpleasant stressor (Pospíšil, 1999). Escalated negative emotions can lead to the mentioned violence with aggression. Frustration, fear and aggression belong amongst the most often felt emotions of both the patient and the healthcare professional.  Frustration or fear themselves do not evoke violence, another factor amplifying emotions is necessary to such an extent, that the “tolerance” is exceeded and an individual lashes out. Other increasing factors (called aversion impulses or precipitators of negative emotions) are insufficient sleep, alcohol, non-alcohol drugs, narcotic addiction, social and financial problems, mental instability, pain, inability to solve stress situations, personal disappointment, illness, failure, lack of respect, decreased adaptation, inter-personal relations. Self-control decides if emotions escalate in the concrete situation and are followed by violence (either verbal or physical) (Špatenková, 2003). We do not agree that only alcohol, addictive drugs or psychiatric diagnosis (as often published in articles, media news or non-professional statements dealing with this item) causes possible violent incidents. The next significant cause of violence is inappropriate communication with people under the influence of addictive substances or with a mental disease. 

There are certain expectations about how staff communicate to patients in healthcare settings. Patients consider healthcare professionals as highly trained professionals and expect from them above all: 

• listening (unfortunately most healthcare professionals can hear the patients (but are not truly listening to them) and pay no attention to the words of the patient. They end up repeating the questions even though the patient may have already told them the information. Attention (it is enough to show attention to  the patient for a couple of minutes – thus the confidence feeling arises and the patient cooperates much better then)
• questions about feelings (let us not presuppose that we know what a patient needs)
• interest for patients’ problems (healthcare professionals very often trivialise patient problems = no emotional routine is possible for patients
• understanding (e.g. careful patient handling when patients say they have pains)
• respecting privacy (both physical and mental)
• respecting personality/individuality (care shall be provided to the patient, not to his illness and its symptoms)
• providing information (each step should be properly explained)
• respectful communication (without jargon and diminutives, a nurse must o introduce her/himself to the patient) 
• meaningful explanation (how to do something instead of what shall the respective person do)
• to show/have respect for the personality;  who the patient is/ originally was (e.g. a patient with dementia or a patient in an acute phase of an illness – their reaction to a care episode can come out from their original job – controller, doctor etc.) 
• empathy and feeling, that a nurse cares about a patient (also a healthcare professional can become a patient)  
• humanity (Howard, 2014, Grimaldi, 2013). 

The wishes and expectations of patients often meets a hard reality in the hospital environment where expectations are not met. Patients declare the following factors as non-professional and devaluing in their contact with a healthcare professional: 

• depreciating domestic methods (herbal teas)
• calling patients by numbers (diagnosis)
• not greeting, not introducing
• indifference towards patients – a healthcare professional doesn´t look at the patient, when she/he speaks with her/him  
• non-verbal gestures (the patient feels that the healthcare professional doesn´t believe her/him).
• waiting  times (leading to frustration)
• lack of privacy
• lack of involvement in treatment decision-making (Thiedke, 2007) 

Media also influences these factors. Patient´s expectations are very often both positively and negatively influenced by her/his experience or experience of relatives or friends. In addition, there is also media and advertisement influence on patients’ expectations. Gross errors of general nurses or, on the contrary, first-rate performances is the most interesting news for the media to report on. The public is unnecessarily suspicious or has exaggerated expectations, which leads to disappointment (Nešpor, 2012).

What we feel and expect from our lives helps us to realise what other people feel and expect from their lives. This empathy and expectations characterises the personality and makes it possible to identify the reality of other people. Our conceptions of other people is rather a conception not corresponding with their personality or feelings but rather a conception of a form enabling a certain relation to them (Grimaldi, 2013). 

In the case of situation difference (a patient who doesn´t collaborate or who is under the influence of drugs, stress or heavy workload of healthcare professionals) there are different conceptions of patients and healthcare professionals. It leads to misunderstandings and stress to an activation of negative emotions causing a feeling of endangerment. The communication of healthcare professionals plays a big role here. Self-control can be strengthened by the knowledge of the fact, that violence is a reaction to the concrete situation but not to the general nurse.

If expectations of the nurse or the patient are not fulfilled, it leads  to  frustration and only a word or a sentence (”Why are you calling me again?!“, “How much did you down?“,”Hurry up!“, ”Can´t you hold your arm without moving for a moment?!“, "Calm yourself!“) or an unsuitable non-verbal expressions (laugh, eye-rolling, disregard of a patient) can lead to a final emotional disgruntlement. In addition, because of this interpersonal interaction, it leads to verbal or physical violence that saturates the need of own safety and decreases the feeling of helplessness. In such situations, communication has a deciding influence upon the result of the conflict. This includes not only words because if we consider communication as a whole, then it means above all behaviour.