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Bachelor in science (Nursing) (BSC Cur)

Research Proposal
Senior Sophister 2010-2011 Title: A quantitative descriptive study exploring: The incidence of violence and aggression towards student nurses in teaching hospitals.

Table of contents Chapter one 1.1 1.2 1.3 1.4 1.5 1.6 1.7 Introduction Alcohol related incidents Staff training Effects of violence and aggression Conclusion Research question Aims and objectives Page number: 4 6 7 9 10 10 10

Chapter two 2.1 Introduction 2.2 Research design 2.3 Population & sample 2.4 Data collection 2.5 Validity and Reliability 2.6 Pilot study 2.7 Data analysis 2.8 Ethical considerations

12 12 13 15 16 17 18 19

Chapter three 3.1 Proposed outcome of study 3.2 Recommendations 3.3 Dissemination of findings 21 21 21

Appendices.

I hereby declare that this Research Proposal is entirely my own work and has not been submitted as an exercise for assessment at this or any other University.

Signed............... Print................... Date....................

Abstract.

The subject of aggression and violence towards nurses within a clinical setting has been researched for many years in different parts of the world. Despite the research that has already been conducted highlighting the on-going and worsening issue of violent and aggressive acts by patients towards nurses, there is little research conducted using student nurses who are the nurses of tomorrow as the sample (Hinchberger 2009). The literature that was examined for the proposal highlights the factors that facilitate these acts of violence and aggression to occur. It also highlights the effects that these incidents have on the person who experiences it in the workplace; however few researchers have investigated the problem as it exists in Irish hospitals, nor used student nurses as the sample population. The literature has highlighted to the author that aggression and violence in the workplace is an ongoing problem that is continuously overlooked as being anything of great significance. The reasoning behind this study is to investigate the factors that allow these acts to occur and to establish whether it is having a damaging effect on Irish student nurses. A descriptive quantitative study will be conducted using a questionnaire adapted from Rose (1997). An estimated 200 nursing students from 2 teaching hospitals in Ireland will be selected as the sample population. Inclusion and exclusion criteria needs will be established before the questionnaires are sent out. A pilot study will first be conducted using 10% of the sample population to test the reliability and validity of the questionnaire. The author will seek the necessary ethical approval before conducting the study. It is anticipated that the findings of this study will highlight the worsening issue of violent and aggressive acts towards student nurses and will hopefully contribute to training courses being implemented within the clinical and academic setting.
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Chapter one The research problem 1.1 Introduction

There are numerous definitions of violence (Saines 1999) defines violence as any episode which puts a health care worker at risk and it includes verbal abuse, threatening behaviour or assault by a patient. Aggression is described as animosity or hostility shown towards another person as a response to frustration or opposition (Burr et al. 1998). Violence and aggression in the health care setting has been ever more acknowledged as a significant problem (Wyke 1994). The majority of nurses working within a health care setting are female and are 3 times more likely to encounter violence than any other professional group (NIOSH 2006). The results of workplace violence towards nurses can have distressing emotional effects such as feelings of anger, sadness, fear and depression (Grenyer et al. 2004). Workplace violence has been linked to the increase of post-traumatic stress disorder, the need for sick leave and reduced levels of work performance and job satisfaction (Jackson et al. 2002). Despite the appreciation of these side effects, many nurses accept aggressive and violent acts as part of the job. Lanza (1992) proposes that by tolerating this workplace violence as a normal event many nurses are desensitizing themselves to working in dangerous and unstable situations. The topic of violence and aggression in the workplace has been widely researched throughout the years and it is noted that the research on violence on nurses generally excludes student nurses in the sampling population (Hinchberger 2009). Published literature has demonstrated the need to acknowledge this problem in Ireland as one studys findings showed that 81-89% of respondents in a sample had been exposed and
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less than one third of heath care staff reported having training in the management of aggression and violence (Ryan 2006). This author has chosen to conduct a research proposal on this topic as they have had direct experience of violence and aggression within the hospital as a student nurse. A review of the literature found that student nurses are frequent targets of aggression and consider themselves as powerless in dealing with it (Beech & Leather 2002). The author believes a study is required to investigate the reasons why violence and aggression occur and what are the effects on the person. The author has conducted a search of relevant literature regarding the issue and with rigorous searches through the databases could find only few studies conducted in an Irish setting, therefore this author believes it may be useful add more research to what is already known about this topic in Ireland. The author used the following databases in the search: CINAHL, ProQuest and internurse, from this search 20 articles were located that were relevant to the topic, manually 3 articles were located within the Trinity College library and 2 anecdotal pieces were considered relevant and included. There were no limitations to the search of relevant literature as the researcher wanted to gain an idea of how much the topic had already been researched.

1.2 Alcohol related incidents. Alcohol is a depressant psychoactive drug which has immense effects on the individuals who consume it (Plant et al.2002). The side effects of alcohol include reduced fear and over reactions, it diminishes the individuals ability to make rational decisions (Graham et al.2003). A distinctive theme evident throughout many of the articles exploring violence and aggression is alcohol. A study by Jenkins et al (1998) found that alcohol was deemed the most likely triggering factor of abuse by 98% of respondents. Similarly a study by Morgan & Steedman (1985) also found that alcohol was documented as a connected factor in 71 out of 102 violent incidents. A study by Crilly et al (2003) was piloted to establish the reason and occurrence of violence towards nurses. A descriptive longitudinal cohort design study was carried out in 2 public emergency departments in Australia. All registered nurses who had patient contact were invited to take part in the study. The final response rate was 66% with 108 participants. The results of the 5 month study showed that 70% of nurses reported violent incidents during this period. A total of 53% reported being verbally abused and 26% experienced episodes of both physical and verbal abuse. The nurses within the study described that they believed alcohol had a giant role to play in these incidents, however without any solid evidence to prove that alcohol was the causative factor and the small sample size they strength of the article was greatly reduced. Schnieden & Marren-Bell (1995) conducted a study to review the types, possible factors and commonness of violence in the workplace. Nurses from the Royal College of nursing where randomly selected and questionnaires were sent to those selected. Demographic details and frequencies of verbal and physical violence were requested. The response rate was 196 out of 300 completed the questionnaire (65%); it was found that 22.9% of nurses said that alcohol was maybe related to physical violence and 73.4 said it was definitely related. 75% of respondents concluded that alcohol was absolutely associated to verbal
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abuse and 21.4% said maybe. Due to lack of under reporting of physical and violent incidents, it is difficult to prove whether alcohol was the causative factor as these findings are based on opinion and they do not support the suggestion alcohol is related to abuse.

1.3

Staff training

Staff training or lack of staff training is a theme that was evident throughout the literature. The literature highlights the differences in the number of nurses who were trained in managing violence and aggression and those who were not. Shah & De (1998) determined that if nurses are mindful of potential triggers of aggression and violence it may result in healthier management of the psychological effects of workplace abuse. Suitable training in the management of aggression and violence is the first step nurses can take to protect themselves as Whittingtion (1997) found that unsuccessful training was a main factor in the incidence of workplace violence. A study by Atawneh et al (2003) was conducted to examine the rates, frequency and severity of violence in a general hospital in Kuwait. The tools used for the study was a 12 item frequency weighted questionnaire. The sample population comprised of all the nurses working within the emergency department of the hospital. With a 94% response rate the researchers from the data collection that 86% reported having experienced violent incidents that included both verbal and physical. Only 15% of the sample had any type of training to cope with aggressive behaviour and 44% believed a training programme would be valuable. Although the small sample size greatly reduces the strength of the study, these findings are supported by Schnieden & Marren-Bells (1995) study on workplace violence in an English hospital. The study comprised of a questionnaire survey on 196 nurses and found that over half of the nurses had received no formal training in managing violent and aggressive patients and only 18.4 had information on
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aggression and violence on an induction course and 89.1% had never received an update. Deans (2004) conducted a study to examine the efficiency of a once off training programme in managing aggressive and violent situations. The research design method involved using a nonexperimental one group pre-test, post-test on a sample of 24 nurses. Deans (2004) proposes that an effective training programme can help nurses reduce the incidents of violence and aggression by 50%. The results from the study found that the occurrence of aggressive situations experienced by nurses was reduced from 11.3% to 3.4% within 3 months. A rise in confidence to deal with potential aggressive situations from 4% to 13% was also noted. The sample size does reduce the strength of the survey however the results show a training programme does work. These findings are supported by Beech & Leathers (2003) study on the prevention and management of aggression for student nurses. The purpose of the study was to measure outcomes of the group of students in the unit and gain more awareness about more general issues in evaluating training effectiveness. The researchers state that student nurses are common targets of aggression but are worryingly less likely to receive specific training. A repeated measures longitudinal design was used to gather data from 3 groups of 20 students over an eight month period. A questionnaire was administered twice before the unit, at its conclusion and approximately 2 months afterwards. They found that statistically substantial changes were demonstrated in a number of areas including number of risk factors identified after the 3 day learning unit. Beech & Leather (2003) state that it is possible to provide training that produces desirable, statistically demonstrable and durable changes in knowledge. Deans (2004) states that continuous training is key in providing nurses with the competence and confidence in dealing with aggressive situations. As todays student nurses will be the working nurses of tomorrow, training programmes should be a core part of their overall nursing training.
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1.4 Effects of violence and aggression Acts of violence and aggressive behaviour towards nurses can have devastating effects on their mental health. There have been many studies that have proven the adverse psychological effects it has on a nurse such as, insomnia, agro phobia and depression (Income data service study 1990). Schnieden (1993) also found that perceived vulnerability to further episodes may lead the nurse to take sick leave, cause poor staff morale and a higher than necessary staff turnover. Atawneh et al (2003) directed a questionnaire survey to measure the effects of violence. The researchers found that 96% of nurses who had experienced violence at work suffered from one or more after effects that included: flashbacks, depression, sleeplessness, fearfulness and time off. It was revealed that 59% suffered all 5 effects. Chapman (2009) found that many nurses who experienced workplace violence questioned their capability as a nurse because they felt overcome and helpless. These findings are reinforced by a questionnaire based survey conducted by Farrell et al (2006). The study focused on nurses working in a hospital in Tasmania and those who had left a position. The researchers found that 11% of the sample said they had left a position in their career due to aggressive incidents, 24% of the sample said they had thought about leaving the position in the last 4 weeks and 2% said they had left the profession altogether because they were unable to cope with the effects of workplace violence. Maslach & Jacksons (1986) theory on burnout suggests that patients being cared for by nurses working in high levels of stress may not receive the best quality of care. Chapman (2009) found that nurses who had been victims of workplace violence had become hesitant to look after aggressive patients. Maslach & Jackson (1986) also established that an individual suffering from burnout may begin to suffer from the 3 common symptoms of burnout: exhaustion, reduced job satisfaction and desensitisation of the client. It is evident from the literature that workplace violence has devastating effects on the nurse who
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experiences it with burnout being one of the major implications of workplace violence and aggression.

1.5 Conclusion Alcohol has been implicated as being the main causative factor in workplace aggression. From studying the literature there was found to be a general consensus that alcohol did indeed play the biggest role, however due underreporting of alcohol related violent incidents and the majority of findings being based on opinion of the participants, the findings lacked credibility. Fern (2005) stated that findings from a study conducted by Jenkins et al (1998) were no more than assumption due to the lack of solid data that prove nurses were experiencing workplace violence by individuals who were under the influence. It is important to note however that nurses working in areas such as the accident and emergency department are more likely to be caring for individuals who are under the influence of alcohol and substance abuse, so it is the researchers aim to highlight the potential problems that can arise from alcohol. Lack of staff training is having a direct impact on the nurses being able to manage violent and aggressive patients in the health care setting. The literature has shown that training programmes in the management of aggression and violence would be valuable, as Deans (2004) study on the usefulness of a once off training programme has proved they do work. Beech & Leather (2004) stated that student nurses are frequent targets of aggression as they are considered powerless, however they are less likely to receive any training in managing violent and aggressive patients which leaves them vulnerable as not only students but when they qualify to workplace violence. The effects of violence and aggression were shown throughout the literature to have horrendous effects on the individual who experiences it. Maslach & Jackson (1986) suggested that burnout has serious
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consequences on the individual which can eventually lead to exiting the profession. Student nurses who are frequent targets of aggressive behaviour may begin to suffer from symptoms of burnout before they have qualified. Aggression and violence towards student nurses must be highlighted because as our government cuts health expenditure and decreased staffing levels are more prevalent on the wards due to the current economic climate, the hospital setting is a very stressful and hard place to be for staff, students and patients alike. Student nurses may find themselves experiencing the backlash of angry patients who are fed up with the health system at present and feel they are not receiving the quality of care they should be getting. 1.6 Research Question The proposed research question is: What is the incidence of violence and aggression by patients towards student nurses and are they able to deal with it effectively? 1.7 Aim & objectives Aim: To determine the incidence of violent and aggressive acts towards students and to investigate whether or not they can effectively deal with it. Objectives (1) (2) (3) (4) To determine the frequency of violence and aggression towards student nurses. To investigate the factors that facilitates violence and aggressive acts to occur. To determine if student nurses can effectively cope with and what impact these violent incidences had on them. To make recommendations for clinical practise and further research.

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Chapter 2: Methodology 2.1 Introduction In this chapter the researcher must select the most suitable methodology to answer the research question. It is anticipated that the chosen methodology will accomplish the aims and objectives of the study. 2.2 Research design Research methods can be divided into two groups: qualitative and quantitative. The purpose of a research design is to describe how, when and where data is to be analysed for the research issue (Parahoo 2006). According to Watson et al (2008) quantitative research is based on numerical data or quantities and is concerned with the detection of general laws. It tends to focus on control of events and claims to be objective (Punch 2005). It produces empirical data which is important for evidence based practise (Parahoo 2006). Parahoo (2006) states that the findings of quantitative research should be generalizable. Alternatively qualitative research methods gather verbal or observational data; it focuses on peoples experiences and understanding these experiences by taking on and insiders perspective. In doing so, researchers acknowledge and use their subjectivity (Morgan & Drury 2003). A qualitative method will not be used for this study as the researcher wishes to obtain factual empirical data on the incidence of violence and aggressive acts towards student nurses, therefore a quantitative method will be used at the data collected can be statistically analysed. The research design chosen to produce data on this topic is a descriptive quantitative study that will use a structured questionnaire. This method of gathering data is advantageous in reducing the risk of researcher bias as the researcher will have very
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little dealings with the participants in the study (Parahoo 2006). The researcher hopes to gather new information on the chosen topic as there is little research done on the incidence of violence and aggression by patients towards student nurses in Ireland. It is anticipated that the data collected in the study will be utilised in nursing education and preparation for clinical placements for future practise.

2.3 Population and sample 2.3.1 Population Polit & Beck (2008) describe a population as being all the individuals or objects with common, defining characteristics from which data can be collected. The target population is a group of subjects that fit the research criteria (LoBiondo-Wood & Haber 1998). The planned population for this research proposal are student nurses who have completed their accident and emergency placement and are in their final year of general nursing. A sample of this population will be selected as due to time constraints it is not achievable to study every student nurse in Ireland. A sample is defined as a subset of the target population (Parahoo 2006). Students from 2 major teaching hospitals in Dublin doing the 4 year degree programme in nursing will be selected as the sample population and must meet the sampling criteria. Inclusion criteria Participants must have completed their accident and emergency placement. Participants must be in their final year of nursing. Participants must be over 18years of age. Participants must be skilled in reading and speaking English Participants must be in the General class of the Nursing degree programme. Exclusion criteria
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Participants not in the general setting Participants not meeting the above criteria.

From this inclusion and exclusion criteria, a sample can be selected.

2.3.2 Sample selection and size The sample is selected so it can provide the researcher with data that is representative of the whole population so that inferences of the population can be made (Polit & Beck 2008). A letter of invite (Appendix 1) for the proposed study will be sent to the Director of the nursing degree programme to gain consent and to gather the samples who meet the criteria. Letters will also be sent to the ethics committee of both hospitals for approval (Appendix 2) The type of sample chosen for this study is non-probability sampling in the form of purposive sampling. Non-probability samples are made up of units whose possibility of selection is not known in advance (Parahoo 2006). Purposive sampling involves the researcher deliberately choosing who to include in the study with the impression that those selected can provide them with the necessary data (Parahoo 2006). Small samples in quantitative research are unlikely to produce results of significance (Parahoo 2006). Large sample sizes are advised in quantitative studies as the more representative it is likely to be to the population (Polit & Beck 2008). In order to try increase the generalizability of the study, 2 major teaching hospitals have been selected. Often with questionnaires the response rate can be low so a larger sample is required to increase the strength of the study, however due to time constraints and funding issues no more than 2 hospitals will be selected. All students who have completed the A&E placement and are in their 4th year of study will be included for the study. An estimated 200 students will be selected as the sample population from the 2 major teaching hospitals.

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2.4 Data Collection Burns and Grove (2003) state that the data collection procedure is the identification of subjects, and the precise systematic gathering of data relevant to the research purpose. The data collection methods are physiological, observational, interviews, questionnaires and records (LoBiondo-Wood 2002). The chosen method for collecting data for this study is a structured questionnaire (Appendix 3). Questionnaires are the most usual method of data collection in social and health research (Parahoo 2006). They are most appropriate for producing data on prevalence, trends, incidence and patterns (Watson et al. 2008) which is the most suitable tool to use to collect data on the research question. Questionnaires are a cheap and quick way of gathering large amounts of data (Parahoo 1997). Questionnaires can potentially guarantee anonymity and this may encourage some respondents to reveal details of behaviour which they may not do in interviews, making them more reliable than other methods (Watson et al. 2008). Disadvantages in using a questionnaire include misinterpretation of a question or the sample not understanding the question which will make the answer useless. If the questionnaire is too long many people will be inpatient with filling it out and not complete the questionnaire which is why it is important to keep it simple and concise. The data for this proposal will be collected using a questionnaire adapted from Roses (1997) questionnaire survey on violence and aggression towards nursing staff in the accident and emergency department. The researcher used this questionnaire and added in 2 open ended questions so the participants could have the opportunity to give more detail about certain points. Developing a questionnaire is systematic, time consuming and painstaking (Watson et al. 2008) and due to time constraints the researcher has chosen this adapted version as appropriate to the study. A letter requesting permission to use and adapt the questionnaire will be sent to the original creator of the tool (Appendix 4). The questionnaire consists of 11 closed ended questions
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with 2 open ended questions to let participants answer in their own words and gain greater insight into the research problem (Burns & Grove 2007). The questions will be short, concise and comprehensive which will hopefully increase the response rate, the questionnaire should take no longer than 10 minutes to complete. A cover letter (Appendix 5) will be included with the questionnaire describing what the research is about; whose research it is and what potential contribution it can make. Assurance of confidentially will be included in the letter (Watson et al. 2008). A stamped addressed envelope will also be included to try and enrich the response rate. A contact address for the researcher will be included should the participants have any queries. A reminder letter will be issued to all participant two weeks after the first questionnaire was sent out to encourage those who have not finished it to do so and to thank those who did (Appendix 6).

2.5 Validity and Reliability There are two key concepts that concern the value of research: validity and reliability (Gerrish & Lacey 2006). For the questionnaire to be of use to the researcher it must produce valid and reliable data (Parahoo 2006). Burns and Grove (2003) state the validity of an instrument is a determination of how well the instrument reflects the abstract concept being examined. There are three different types of validity: content validity, predictive validity and construct validity (Burns & Grove 2003). Content validity is the degree to which the items in an instrument adequately represent the universe of content for the concept being measured (Polit & Beck 2004). The questionnaire will be sent to a group of professionals who have the expert experience and knowledge in the area of aggression and violence within an acute setting, so they can analyse the tool and make suggestions to better improve it if necessary. The group will consist of nurses with research backgrounds, clinical nurse managers and college lecturers. Face validity is another method in measuring the validity of a tool. It confirms that a measuring
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instrument looks as though it is measuring what it means to measure (Polit & Beck 2004). Face validity will be assessed by friends and family who will study the questions to ensure they are concise and easy to complete (Polit & Beck 2004). 2.5.1 Reliability Polit & Beck (2004) describe reliability as being the degree of consistency or dependability with which an instrument measures on attribute. Reliability is concerned with the dependability of results from the questionnaire (Burns & Grove 2007). The reliability of the questionnaire will be tested using the test-re-test reliability method, which involves administering the same questionnaire to the same people after a certain period of time. The reliability of the questionnaire can be estimated by examining the consistency of responses between the two sets of data (Gerrish & Lacey 2006). Reliability is measured by numbers called coefficients. If the same result is achieved both times the questionnaire is administered then the reliability coefficient will be 1.00. Burns & Grove (2003) state that reliability coefficients that have a score higher than 0.70 are deemed acceptable. The researcher will aim to achieve a reliability score of 0.70 for the study. 2.6 Pilot study A pilot study of the questionnaire will be performed before data collection commences. (Watson et al. 2008). A pilot study is a smaller version or trial run devised to test the methods to be used in a larger more rigorous study (Polit & Beck 2004). According to Gerrish & Lacey (2006) a pilot study will tell reviewers what steps will be taken to ensure that the proposed methods are workable, are acceptable to subjects and manageable. The pilot study will allow the researcher to determine the clarity of the questionnaire, the length of time taken to complete it and to see if the questionnaire is too extensive (Polit & Beck 2004). The pilot study will be conducted in the same method to the proposed study using approximately 10% of the target sample. Those
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who are selected for the pilot study will not be included in the main study. The researcher will send a letter of approval to the Director of Nursing in the 2 hospitals. The proposed questionnaire for the main study will be used in the pilot study. The questionnaires will be analysed upon completion using the data collection tool and any errors and alterations to the questionnaire can be made if necessary. The data analysis method will also be tested. The results from the pilot study will not be included in the results of the main study.

2.7 Data analysis Data analysis is possibly the biggest and most important phase of the research project, once the data has been collected they need to be organised and assembled in such a way that conclusions can be drawn from them (Gerrish & Lacey 2006). Data analysis is conducted to reduce, organise and give meaning to the data (Burns & Grove 2003). The questionnaires will be pre coded during the data collection stage as they are useful in linking the data collected on paper and the data stored on the computer as it contains information about how the individual variables are to be named, labelled and coded in the chosen computer package (Gerrish & Lacey 2006). The pre coded questionnaires will then be entered onto the computer to be analysed. The analysis will be done using the SPSS (Statistical Package for the Social Sciences). A statistician will be consulted to analyse the data so the results can be written up. 2.7.1 Describing quantitative data When analysing the data, the first approach would be to calculate summary measures, to describe the location (measure of the middle value) and the spread (a measure of the dispersion of the values) (Gerrish & Lacey 2006). In measuring the location the easiest method is the mode. It is the most common observation. The median is the middle observation and the data are arranged in order of increasing value
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(Gerrish & Lacey 2006). The mean is simply the sum of all the observations divided by the number of observations and is the most useful measure of the central value of the data.

2.8 Ethical considerations The main ethical issues which should be contemplated before the research study can be commenced are: consent, confidentially, beneficence, non-maleficence and justice (Burns & Grove 2007). Ethical

approval from Research Ethics Committee will be obtained before the study is commenced as well as the letter of invite to the Director of the nursing degree programme. Informed consent will be obtained by the researcher
by providing full information that is concise on what the research is about to the proposed participants by including an information letter with the questionnaires. The participants will be assured of their confidentially as the questionnaires are not identifiable through names and all data collected will be held in a secure area. All participants will be made aware of the benefits of the study, the study aims to determine the incidence of violence and aggression towards student nurses, which best serves the interest of those taking part. All data collected will be stored on a laptop which is password protected and all raw data will be destroyed after five years. Non maleficence is a term that is linked with the concept that it is better not to harm the participants than do them good. All proposed participants will be fully aware of what the research questionnaire entails and have the right to withdraw from the study without consequences. To assure justice all participants will be treated fairly with no individual receiving preferential treatment (Burns & Grove 2007). As previously mentioned a letter of approval will be sent to the ethics committee prior to commencement of the study.

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Chapter 3 3.1 Proposed outcome of study Upon completion of the research study the author will construct a report highlighting the findings. When writing up the findings the author will be vigilant not to project their own bias in this part of the study. It is anticipated that the instrument used for data collection will produce findings of importance to the research. The author ensured the questionnaire used for data collection was concise and simple to complete to ensure full completion of the questionnaire. The limitations to this study is the fact that the study was only carried out in two teaching hospitals in Ireland, which will reduce the chance of generalising the findings of the study to all teaching hospitals in Ireland. The author anticipates that the study will highlight the incidences of violent and aggressive behaviour towards student nurses, and increase the awareness of potential causes of these acts. It is hoped that the end results of the study will establish a need for more training and management techniques of aggressive and violent behaviour within the clinical setting and tutorial classes.

3.2 Recommendations The author recommends that a larger study of the same issue should be conducted in other teaching hospitals throughout Ireland so that the results can be compared in order to generalise the findings.

3.3 Dissemination of findings. The findings of the study will be disseminated to the two participating teaching hospitals and the School of Nursing and Midwifery. The
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findings of the study will also be discussed with the Director of Nursing and the head of the School of Nursing and Midwifery if possible in order to increase the awareness of violent and aggressive acts towards student nurses. It is anticipated that the study will be published in nursing journals to give other nurses and students access to the study.

3.4 Time scale. A clear timetable with objectives to be achieved throughout the study process demonstrates that the proposal is realistic and achievable (Cormack, 2000).The author anticipates that it will take 16-18 months to conduct the proposed study. The proposed time layout is found in (Appendix 7).

3.5 Budget. The predicted budget for the study can be found in (Appendix 8)

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Plant M., Thornton C. (2002) People and places: some factors in the alcohol violence link. Journal of Substance Abuse 7:207-213. Polit D.F & Beck C.T. (2008) Nursing Research: Generating and Assessing Evidence for Nursing Practice, 8th edn. Lippincott, Williams & Wilkins. Philadelphia. Polit DF, Beck CT. (2004) Nursing Research: Principles and Methods. Lippincott Williams & Wilkins, Philadelphia. Punch K.F. (2005) Introduction to Social Research: Quantitative and Qualitative Approaches, 2nd edn. Sage, Thousand Oakes, CA. Rose M. (1997) A survey of violence towards nursing staff in one large Irish Accident and Emergency department. Journal of Emergency Nursing 23(3), 214-219. Ryan D. (2006) Aggression and violence- a problem in Irish Accident and Emergency departments? Journal of Nursing Management 14, 106115. Saines J. (1999) Violence and aggression in A&E. Accident and Emergency Nursing 7(1), 8-12 Schnieden V (1993) Violence at work. Archive of Emergency Medicine 10, 79-85 Schnieden V., Marren-Bell U. (1995) Violence in the Accident and Emergency department. Accident and Emergency Nursing 3, 74-78. Shah A., De T. (1998) The effects of an educational intervention package about aggressive behaviour directed at the nursing staff on a continuing care psycho geriatric ward. International Journal of Geriatric Psychiatry 13, 35-40. Watson K., McKenna H., Cowman S., & Kneady J. (2008) Nursing Research: Designs and Methods. Elsevier Press. Whittingtion R. (1997) Violence to nurses: prevalence and risk factors. Nursing Standard 12(5), 49-56. Wykes T. (1994) Violence and Health Care Professionals. Chapman & Hall, London.

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Appendix 1 Letter to the Director of Nursing: 1st March

Dear Sir/Madam,

I am currently in my fourth and final year of General Nursing in Trinity College Dublin. As part of my final piece of academic work for college I am required to conduct a research proposal. The study I intend to undertake is a quantitative study using a structured questionnaire. My aim is to determine the incidence of violent and aggressive acts towards student nurses and to investigate the factors that facilitate violent acts to occur. The study comprises of 100 General Nursing students from this hospital and another 100 from a different teaching hospital in Ireland and participants are invited to complete a simple questionnaire which will hopefully yield findings of relevance to the study. The inclusion criteria for the study states that the sample of nursing students must be in their 4th year of the general nursing degree and have completed their A&E placement. I am writing to request your permission to carry out this study in your hospital and would appreciate if you could appoint a gate keeper to distribute the questionnaires to those that meet the criteria. If you would like some more information on the research study please do not hesitate to contact me. Thank you for taking the time to read this letter. Yours Sincerely Ciara Kelly

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Appendix 2 Letter to the ethics committee: Ethics committee XXXX Hospital To whom it may concern I am currently in my fourth and final year of General Nursing in Trinity College Dublin. As part of my final piece of academic work for college I am required to conduct a research proposal. The study I intend to undertake is a quantitative study using a structured questionnaire. My aim is to determine the incidence of violent and aggressive acts towards student nurses and to investigate the factors that facilitate violent acts to occur. The study comprises of 100 General Nursing students from this hospital and another 100 from a different teaching hospital in Ireland and participants are invited to complete a simple questionnaire which will hopefully yield findings of relevance to the study. The inclusion criteria for the study states that the sample of nursing students must be in their 4th year of the general nursing degree and have completed their A&E placement. A cover letter with each questionnaire will be sent to each participant. Consent is implied upon completion of the questionnaire. Confidentiality and anonymity will be assured at all times. I would appreciate your approval to undertake this study in the hospital. Thank you for taking the time to read this letter. Yours faithfully, Ciara Kelly.

1st March

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APPENDIX 3

Questionnaire for student nurses (Adapted from Roses (1997) questionnaire survey on violence and aggression towards nursing staff in the accident and emergency department Violence and aggression while on placement. Please tick the box that applies to you: 1: Sex 2: Age Female 18-25 Male 26-30 30+

3: Have you ever been abused by a patient or relative while working in the hospital? Was it physical or verbal abuse Verbal physical both? 4: If so, how many times? Never 1-3 4-9

10-15

15+

5: How long ago was the most recent incident? 0-3mths 4-6mths 7mths-1yr 2-4years 6: What clinical area did it occur in? A&E Female ward Male ward Care of the elderly patient 7: Was it: Day duty Night Duty Yes No.

Mixed Gender Ward

8: Did you take sick leave? If yes state how long

9: What day of the week was it?

Monday Friday

Weekend

10: Did you report the incident and if so was the response helpful? Yes No
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11: Do you worry about being verbally or physically abused while on placement? Yes No

What do you think was the causative factor in the violent and aggressive act? Did the incident question whether you wanted to, or felt able to continue on in the course? (Please explain in detail).

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Appendix 4
Ms Mary Rose 24 XXXX Estates 1ST March. Dear Mary, My name is Ciara Kelly and I am currently in my fourth and final year of General Nursing in Trinity College Dublin. As part of my final piece of academic work for college I am required to conduct a research proposal. The study I intend to undertake is a quantitative study using a structured questionnaire. My aim is to determine the incidence of violent and aggressive acts towards student nurses and to investigate the factors that facilitate violent acts to occur. When conducting my literature review I came across your article: A survey of violence towards nursing staff in one large Irish Accident and Emergency department and noticed that you used a questionnaire to gather your data. I am asking for your permission to use your questionnaire as part of my research proposal. I will have to slightly adjust some parts in order to make it relevant to my proposed study by adding in some questions of my own. I would really appreciate your approval to do so and complete my research proposal. Yours Sincerely, Ciara Kelly.

Appendix 5
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Cover Letter to Participants. 1st March Dear Sir/Madam, I am currently in my fourth and final year of General Nursing in Trinity College Dublin. As part of my final piece of academic work for college I am required to conduct a research proposal. The study I intend to undertake is a quantitative study using a structured questionnaire. My aim is to determine the incidence of violent and aggressive acts towards student nurses and to investigate the factors that facilitate violent acts to occur. The study comprises of 100 General Nursing students from this hospital and another 100 from a different teaching hospital in Ireland and participants are invited to complete a simple questionnaire which will hopefully yield findings of relevance to the study. The inclusion criteria for the study states that the sample of nursing students must be in their 4th year of the general nursing degree and have completed their A&E placement. (Saines 1999) defines violence as any episode which puts a health care worker at risk and it includes verbal abuse, threatening behaviour or assault by a patient. Aggression is described as animosity or hostility shown towards another person as a response to frustration or opposition (Burr et al. 1998). There is very little research conducted on the incident of violent and aggressive acts towards student nurses. If you would like to take part in this study, you will be required to complete the questionnaire and return it in the stamped addressed envelope which will be sealed for confidentiality. I have assigned a gatekeeper to this study to ensure confidentiality and reduce researched bias. Consent for the study will be implied upon completion of returned questionnaires. You may withdraw from the study at any stage. Thank you for taking the time to read this letter. Yours sincerely, Ciara Kelly.

Appendix 6
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Reminder Letter. Dear Sir/Madam, I am writing to give a gentle reminder to complete your questionnaire if you have not already done so. Upon completion the questionnaire should be sent in the stamped addressed envelope. Your anonymity and confidentiality is guaranteed at all stages and should you wish to withdraw from the study at any stage you may do so. Thank you for taking the time to read this letter. Yours Sincerely, Ciara Kelly.

Appendix 7
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Time Scale.
Month jan literature ethics sample pilot data coll analysis findings feb mar apr may jun jul aug sep nov dec jan feb mar apr may

Finished. In progress

Appendix 8
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Budget.

Expenditure: Personnel Gatekeeper salary (2 months salary @ 65 per day. Statistician and SPSS 3,000 Materials Stationary Photocopying / Printing/ Ink Cartridges etc. Postage and envelopes USB 45.00 25.00 150.00 10.00 3,900

Cost

Presentation Binding of finished research leaflets Internet and Telephone Costs 20.00 40.00 50.00

Total

7240.00

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