PERoPA the nurse managers’ perspective

An international research collaboration examining patient and visitor aggression in healthcare organizations from the nurse managers' perspective.


  • Lead school(s) School of Health Professions
  • Funding organisation Netzwerk Aggressionsmanagement im Gesundheits- und Sozialwesen Austria – NAGS
    Verein Netzwerk Aggressionsmanagement im Gesundheits- und Sozialwesen Schweiz
    Sigma Theta Tau International
    Stiftung Lindenhof, Bern
    Schweizer Berufsverband der Pflegefachfrauen und Pflegefachmänner (SBK)
  • Duration (planned) 01.01.2017 - 31.12.2019
  • Project management Prof. Dr. Sabine Hahn
  • Head of project Dr. Birgit Heckemann
  • Partner Pflegenetz

Patient and Visitor Aggression (PVA) occurs in all clinical healthcare areas. Furthermore, PVA is an international phenomenon that affects healthcare professionals across the globe, causing considerable human suffering and incurring substantial financial costs.

International studies show that workplace aggression affects staff intention to change jobs or to abandon an occupation in healthcare altogether. Moreover, aggression reduces patient safety and quality of care.

To date, little is known about how nurse managers experience and manage PVA, although the link between leadership, workplace safety, job satisfaction and quality of care has been recognised.

PERoPA aims to obtain an international overview of PVA in general and mental health hospitals, from a nurse managers' perspective. Specifically, we will collect information on how nurse leaders experience PVA, what they do about PVA and the obstacles and opportunities they encounter in their efforts to tackle PVA.

PERoPA is a sequential mixed methods project comprising two sub studies.
Sub study 1 is an interview study with nurse managers. Between October 2015 and January 2016, we conducted 15 individual interviews and five focus groups in the German-speaking part of Switzerland. The interviews were analysed during spring 2016. The results contributed to the design of a questionnaire, our data collection tool for sub study 2

Sub study 2 is an international electronic survey aimed at obtaining an overview of PVA from a nurse manager perspective. The questionnaire is purpose designed. In addition to content generated through sub study 1, it contains questions from scientifically evaluated instruments to record and measure PVA.
Between November 2016 and February 2017 we conducted the survey in the German-speaking countries Switzerland, Austria and Germany. The data collection in English-speaking countries (Canada, Great Britain and the United States of America) is currently underway.
The results of the PERoPA project will be published internationally. Moreover, they will contribute further develop a model aimed at helping nurse managers to reduce PVA in healthcare more effectively.

Switzerland, Austria and Germany

  • This research project is lead by Principal Investigator Prof Sabine Hahn, RN PhD. Sabine Hahn is the Director of the Division of Nursing and Division Head of Applied Research & Development in Nursing at Bern University of Applied Sciences, Bern, Switzerland.
  • Birgit Heckemann, RN, PhD is the study coordinator and contact person for the data collection in Switzerland, Austria and Germany. 


  • Bridget Hamilton, PhD, Senior Lecturer, Associate professor Department of Nursing, The University of Melbourne, Clinical Nurse Consultant, St. Vincent’s Mental Health, Australia
  • Marie Gerdtz, PhD, Associate Professor of Emergency Nursing, The University of Melbourne, Australia


  • Sanaz Riahi, Director, Professional Practice & Clinical Information, Ontario Shores Centre for Mental Health Sciences, Canada

Great Britain

  • Joy Duxbury, PhD, Professor of Mental Health Nursing, University of Central Lancashire, United Kingdom

The United States of America

  • Joanne DeSanto Iennaco, PhD, Associate Professor of Nursing and Psychiatric-Mental Health Nurse Practitioner Specialty Coordinator, Division of Primary Care, Yale School of Nursing, USA


First study results were presented 2017 in an oral presentation at the 10th European Congress on Violence in Clinical Psychiatry in Dublin, Ireland.

Peer reviewed publications

  • Heckemann, B., et al. (2017). «Nurse managers: determinants and behaviours in relation to patient and visitor aggression in general hospitals. A qualitative study.» Journal Of Advanced Nursing 73(12): 3050-3060.
  • Heckemann B, Sigrist-Dreier S, Thilo FJS & Hahn S. (submitted). Team efficacy and leadership in managing aggressive situations in the general hospital setting. A qualitative descriptive analysis of focus groups with ward managers.
  • Heckemann B, Hahn S, Halfens RJG, Richter D, Schols JMGA (2019). Patient and visitor aggression in healthcare: A survey exploring organisational safety culture and team efficacy. Journal of Nursing Management. 27(5):1039-1046 doi: 10.1111/jonm.12772.
  • Heckemann B & Thilo, FJS (2019). Working via distance: Using Computer-Assisted Qualitative Data Analysis Software (CAQDAS) MAXQDA, email and teleconferencing in Qualitative Content Analysis - Experiences, Pitfalls and Practical Tips. SAGE Case study (Accepted for publication)
  • Heckemann B, Peter K, Kok G, Schols J.M.G.A. & Halfens R.J.G. & Hahn S (2017). Nurse managers: determinants and behaviours in relation to patient and visitor aggression in general hospitals. A qualitative study Journal of Advanced Nursing. 2017;73(12):3050-60. doi: 10.1111/jan.13366


  • Heckemann B, Thomann S, Hahn S (2018). Bei der Prävention von Aggression sind die Führungskräfte gefordert. Krankenpflege/Soins infirmiers/Cure infermieristiche (12):25-27.

Conference abstracts and proceedings




  • Heckemann B, Hahn S, Duxbury J, Riahi S, Hamilton, B & DeSanto Iennaco J. Comparing settings: a survey of nurse managers exploring organizational safety culture against aggression in psychiatric and general hospitals. The 11th European Congress on Violence in Clinical Psychiatry, 24-26 October, Oslo / Lillestrøm – Norway.
  • Heckemann B, Hahn S, Duxbury J, Riahi S, Hamilton, B & DeSanto Iennaco J. Dealing with patient and visitor aggression in healthcare: a workshop exploring future responsibilities in leadership (workshop presentation). The 11th European Congress on Violence in Clinical Psychiatry, 24-26 October, Oslo / Lillestrøm – Norway.
  • Heckemann, B. & Hahn, S. Herausforderung Patienten- und Angehörigenaggression: Ergebnisse einer internationalen Umfrage unter PflegemanagerInnen. Pflegekongress19. Vienna, Austria, 2-3 October.
  • Heckemann, B. & Hahn, S. Anspruch und Wirklichkeit: Eine internationale Analyse der Herausforderung PatientInnen und Angehörigenaggression aus der Pflegemanagement Perspektive. [Aspirations and Reality: An international analysis of the challenge of patient and visitor aggression from the nurse manager perspective]. high noon – Paradigmenwechsel: wir geben Menschlichkeit zurück!, Frankfurt, Germany, 14-15 November.
  • Heckemann, B. Organizational safety culture against aggression. Oral presentation. The European Violence in Psychiatry Research Group (EViPRG) Spring meeting. Bern, Switzerland, 4-5 April.


  • Hahn S, Richter D, Peter K & Heckemann B. Aggression and healthcare professionals– different perspectives, different needs (Symposium). STTI 4th European conference, Cambridge, UK, 4–6 June.
  • Thomann S, Heckemann B, Hahn S. Aggression ist Chefsache. Let’s get loud – Für eine starke Pflege! SBK Kongress 2018; 2018 2-4 Mai 2018; St. Gallen, Switzerland.


  • Heckemann, B, Hahn, S. Aggression von PatientInnen und BesucherInnen. Wie denken PflegemanagerInnen darüber? Wie handeln sie? [Patient and visitor aggression. What do nurse managers think? What do they do?] Oral presentation. High Noon? Gewalt und Deeskalation in Sozial und Gesundheitseinrichtungen, Vienna, Austria, 6–7 December.
  • Heckemann, B, Hahn, S. PatientInnen und BesucherInnen Aggression aus Sicht von PflegemanagerInnen. Die PERoPA Projektergebnisse [Patient and visitor from a nurse manager perspective. Results of the PERoPA study]. Oral presentation. Pflegekongress 17, Vienna, Austria, 30 Nov–1 December.
  • Heckemann B, Duxbury J, Gerdtz M, Hamilton B, Riahi S, De Santo Iennaco J & Hahn S. Perception of Patient and Visitor Aggression (PERoPA). First results of an international project investigating the nurse managers' perspective on the management of aggression in healthcare”. Oral presentation. The 10thEuropean Congress on Violence in Clinical Psychiatry, Dublin, Ireland, 26–28 October.


  • Heckemann B, Halfens, RJG, Schols JMGA, Peter K, Kok G, Hahn S. Challenges, opportunities and behaviours: how nurse managers deal with patient / visitor aggression in general hospitals. Oral presentation. The fifth international conference on violence in the health sector, Dublin, Ireland, 26¬28 October.

Project team at BFH