Aggressive Behavior and Its Triggers Among Hospitalized Stroke Patients’ Entourages Toward Healthcare Staff

Aggression toward staff and workplace violence are common problems worldwide (1) that not only affect individuals' dignity but also affect their physical and emotional well-being (2). Aggression and workplace violence as one of the most serious problems threatens the health staff, especially hospitals (3) and may have adverse effects including damage, traumatic attacks on others, and high-risk behaviors (4). Generally the incidence of this problem is increasing so that the incidence of aggression toward staff in hospitals in Great Britain was reported at 42%, in Italy was 74%, in Australia was 93%, in South Korea was 9.7-63.8%, in Turkey was 72.3%, in Jordan was 75%, in Palestine was 76.1%, in Iran was 47.91 - 77.1 % (2, 5-14).

Aggression toward staff as an important factor in reducing the quality of working life and satisfaction with medical staff has a significant effect on the quality of patient's care and their satisfaction and productivity and efficiency of relevant staff (15). This leads to the incidence of moral conflicts among staff and the emergence of psychological symptoms such as anger, stress, depression, and hopelessness and doubts about professional qualifications, the individual proper decisions on the choice of occupation, difficulty in returning to work and the emergence of problems in relations with colleagues (16). In addition, increased medical errors, reduced quality of patient care, absence from work, and increased costs due to sick leave are other consequences of this problem (17).

Although aggression toward staff has several reasons, alcohol and drug abuse by patients or their entourages, lack of security facilities, patients' death and lack of educational facilities for the prevention of violence, (11) perceived delay in the delivery of services and lack of awareness, (12) and night visit and dissatisfaction with the units (14) are mentioned as the main reasons. Ayranci stated that aggression is solely in 52% of patients and the reason for 89% of the aggression is not the patients but also their entourage (8) Another study also notes that entourages show aggression and violence three times to patients (14). This shows the need to examine aggression correlates to the health staff, particularly in units involving patients with sudden problems such as a stroke.

Stroke is a debilitating condition leading to death that involves one person every 40 seconds and 800 thousand people annually in the United States (18). Since in 75% of cases a patient experiences the first stroke previously he had no history, (18) it seems the patient and family members are not prepared to deal with this problem. Although the results of a study showed that there isn't a connection between the quality of life for stroke patients and their family caregivers, (19) other studies suggest that the family caregivers such as patient spouses also reported high burden, more anxiety and depressive symptoms, and less psychological functioning and wellbeing (20, 21). Furthermore, although there is a risk of impulsive behaviors incidence by relatives of the patient from pre-hospital, hospitalization and discharge, it seems that some entourages are more prone to aggressive behaviors incidence. On the other hand, many government hospitals in Iran do not provide adequate welfare and hotel services for caregivers of patients with severe disabilities such as stroke. Caregivers not only do not have enough nutrition and sleep but also worry about the destructive consequences such as chronic disability and death of their patients. Such problems in Iran's cultural context usually make caregivers extremely irritable. On the other hand, examining the phenomenon underlying factors can increase health professional's understanding and since the phenomenon of workplace aggression and violence in hospitals, especially in Middle East countries, has been poorly recorded and managed (10).

This study was conducted aimed to examine correlates of the aggression among entourages of hospitalized stroke patients’ toward health staff.

The high rate of subjective anger and verbal aggression that was obtained in our study is consistent with the results of different studies around the world (5-14). While previous studies have focused more on the role of lack of security facilities, perceived delay in the delivery of services, (12) and dissatisfaction with the units, (14) burden, anxiety, and depression, (20, 21) our results showed that entourages with academic education, patients' spouses, and those with less satisfaction from aspects of hospital stay and physical comfort are more susceptible to subjective anger. In addition, those with academic education, those who are less satisfied with staff behaviors, and those who are more satisfied with physician care are likely to show verbal aggression.

Why entourages with academic education compared to groups with less education are more prone to subjective anger and verbal aggression? The results of a study suggest that increased education is associated with lower satisfaction with health care (25). Since by increasing educational level, generally, the perception and expectation of the quantity and quality of health care services are increased, in such cases, medical personnel should show more empathy and respect for patients and their entourages (26).

Other findings indicated that patients' spouses compared with their siblings are more susceptible to subjective anger. It is quite plausible that a debilitating disease and its treatment not only affect the patient but also his family care, especially when the spouse is the patient (27). With the spouses' satisfaction increased after 1 to 2 years of stroke, (28) usually patients' spouses have no positive assessment of the patient care experience and their perception due to the pressure related to the patient treatment trend causes assuming the lower quality of life (29). Changes in income resulting from treatment because of hospitalization or care and increased costs because of treatment trends, health status, stress and perceived threat, and physical changes associated with the emergence of diseases of aging also influence the spouse negative evaluation (29). On the other hand, in fatal and acute diseases such as stroke, regardless of a couple's relationship intimacy the disease intensity reduced the spouse's emotional well-being (30). In this situation, things like delivering psychological services for the patient's spouse by the hospital staff, providing clear information about the patient's future conditions and outcomes, providing subsidies to reduce the financial burden on the family, and teaching stress coping strategies can be useful. To older spouses, better quality welfare services by the hospital and family and social support are also helpful.

In line with the results of several studies (11, 12, 14, 31) it was found that those with lower satisfaction with aspects of hospital stay and physical comfort, are more susceptible to subjective anger and those who are less satisfied with staff behaviors show more verbal aggression. According to previous studies, less satisfaction with the lack of facilities and aspects of hospital stay and physical comfort affects 34.4% of verbal aggression (32) and less satisfaction with the behaviors of staff is the reason for 11.5% of aggression (31). Obviously physiological needs are the first necessities that if they are not met cause a reaction. In our study hospital, despite appropriate diagnosis and treatment facilities, entourages other than a chair had no bed to lie and rest. If they are present in the hospital for several days and nights in the hospital, fatigue and lack of sleep can be enough to facilitate subjective anger. In addition, entourages receive no food and it is necessary to go to the hospital restaurant for food and in addition to the direct cost paid for the food they leave the patient for a few minutes alone, this problem often causes their complaint.

Finally, our results showed those who are more satisfied with physician care are more exposed to verbal aggression. Overall, participants were more satisfied with physician's care than nurses. It seems when physicians show more empathy and respect for entourages, the patients perceive more empathy and respect of them, (26) their expectations of other staff will be increased but in practice, they see no changes in interaction with them. Given that some of the participants in our study pointed out that “non-physician staff” is not like physicians, do not do their tasks correctly and do not consider our needs it seems an increase in satisfaction with physician care due to rising expectations of other medical staff to provide better services is one of the causes of verbal aggression incidence.

Although some patients had several entourages we only examined one of them who was beside the patient at the time. Also, because our time of completing the scales was between 8 am to 8 pm, we could not examine those who only attended on the night shift at the hospital for patient care. Therefore, it is recommended that future studies examine all entourages on the day and night shifts.