Nursing

In 2006, a Boston-area emergency department (ED) nurse was attacked by an intoxicated, HIV-infected female, and ended up covered in her blood. The following year, that same nurse was grabbed by a patient, who proceeded to issue verbal threats.¹ Then just two months ago, a patient severely beat a psychiatric nurse during a night shift at a state mental hospital in Raleigh, NC.²

While these stories might seem extreme, violence in the workplace is not an aberration, especially among healthcare professionals. Research shows those in the healthcare sector are 16 times more likely to be confronted with violence on the job than any other service profession.³

But rather than simply view such incidents as "part of the job," nurses across specialties and geographic regions are standing up, speaking out, and taking action.

Widespread phenomenon

The Workplace Violence Research Institute (WVRI) officially defines workplace violence as "any act against an employee that creates a hostile work environment and negatively affects the employee, either physically or psychologically."

Unfortunately, nurses and other personnel practicing in acute care facilities, outpatient clinics, and even physicians' offices know this all too well. "Violence against nurses has always been prevalent," asserted Denise King, RN, MSN, CEN, senior consultant for Blue Jay Consulting, an Orlando, FL-based firm specializing in ED services. She also is the current president of the Emergency Nurses Association and boasts 24 years on the job. "We have always had patients who are angry, upset, combative, or altered due to some chemical or physical imbalance, and who take out their aggressions on the staff."

Each individual nurse may face violent or potentially violent situations only once in a while, but the overall numbers are sobering. WVRI estimates more than 16,000 threats are made each day across industries, while at least 700 workers are attacked, and another 43,800 are harassed.⁴ The National Institute of Occupational Safety and Health further refined the figures for just healthcare workers, and determined that more than 9,000 healthcare staff members are either verbally or physically abused on the job every day.³

Yet another study, published in the Journal of Emergency Nursing, reported that approximately 90% of all nurses queried—regardless of specialty—said they had been verbally assaulted over a 12-month span. Three out of four of the individuals surveyed claimed to have been physically attacked during the same time period.³

However daunting the statistics appear, they may not tell the entire story. ENA research reveals that half of all assaults by patients or family members against nurses go unreported.⁵ The organization cites several reasons why clinicians might refuse to officially inform employers or local authorities about violent incidents. For example, lack of formal policies may leave staff unsure of the specific steps to follow; and others might fear that reporting an attack will reflect poorly on their job performance.

"Nurses might feel that if they report the assault to the police, they could run the risk of losing their jobs. That is a huge barrier to reducing the rate of violence in the workplace," said King.

Also, nurses have long held the view that dealing with disgruntled patients and family members is a routine aspect of their responsibilities. "Some nurses look at violence in the workplace as 'part of the job' and will not identify themselves as victims," said Michele Valentino, MSN, CNF, BC, NP, a nurse manager and clinic nurse specialist at Lewis Stokes Veterans Health Administration Community Outpatient Clinic in Canton, OH. Valentino, a psychiatric nurse who has been practicing for 18 years, plans to retire in January.

When patients get physical

"As a manager, I have had nurses report incidents of violence such as being punched in the face by patients. One of my nurses even had her jaw broken, and she is still undergoing reconstructive surgeries," said King.

Such stories capture our attention because there is a physical element to the abuse, with patients or their family members becoming irate with staff and lashing out. The tension can build over time. "They are frustrated and scared about being in the hospital and the unknowns that come with it," offered Cindy Ward, MSN, RNC, CMSRN, a registered nurse level IV at Centra Health's Lynchburg General Hospital in Virginia. The medical/surgical specialist has 27 years of experience. "Patients and their loved ones want answers, and we do not always have the answers. Or, sometimes people have a long wait, and the longer they wait, the more frustrated they can become.

"Most of my personal experience of violence on the job comes from caring for individuals suffering from some form of dementia. I think that type of circumstance is pretty common because these patients may not know why they are in the hospital, and therefore become combative. In those cases, I usually have another staff member accompany me into the room so together we can defuse the situation. It is crucial you remain as calm as possible."

"Their lives are in some type of crisis already," added King. "It is not unusual for people to come into a crowded ED where they are asked to wait. That leads to highly emotional states of frustration and anger, which can then step up to violence."

Because the ED also receives trauma cases, such as gunshot wounds and stabbings, it is the unit most likely to encounter violence from an outside source. For example, gang activity can spill over from the streets to the ED.

"If there is a lot of illegal activity in the area, then that definitely becomes a major concern for emergency personnel. To prevent such incidents, many facilities have installed physical barriers," King said. "It is rare to find to an ED where anyone can walk in because the doors are rigged electronically to control access. In some departments, even the patient registration area is enclosed in glass to create a barrier and make it more of a challenge for unauthorized individuals to gain access to the department."

Some facilities have hired security guards to help maintain a peaceful environment. "Their mere uniformed presence is enough to calm people," King said.

Words can also harm

Not all violence in the workplace is of a physical nature. There are many forms of abuse, including verbal and emotional. And those initiating the attacks are not necessarily outsiders. There is a substantial degree of nurse-on-nurse or physician-on-nurse abuse, otherwise known as lateral or horizontal violence. While some units, such as the ED, are more prone to physical altercations, this type of abuse can happen in any setting. In a multihospital study, 93% of staff respondents stated they had witnessed disruptive behavior by doctors toward co-workers.⁵

Valentino has personally experienced this type of scenario. "It started out insignificantly and became monumental, and it took many months to resolve. When the nurses reported the physician, the response we received from administrators was the typical 'document everything.' But when you write and write, and the person's behavior either continues or escalates, resentment starts to brew. After about eight months of this back-and-forth communication between nurses and management, an attorney was called in and assured us the situation would be rectified because it really had become unbearable. Not long after, that physician left the facility.

"The one factor I learned from this is that in order for nurses to get through a situation like that, we really needed to support each other," Valentino said.

Taking action

Personal safety in the workplace has always been a concern of nurses, but it seems to be taking center stage more often. "At the last Academy of Medical-Surgical Nurses convention, we held a town hall session where members could discuss anything on their minds," Ward noted. "A lot of attendees brought up violence in the workplace and employee safety."

"The American Psychiatric Nurses Association [APNA] also conducted a study a few years ago to determine what concerns staff nurses had regarding their profession," said Valentino. "Their top concerns were staffing numbers and personal safety on the job, and I do not necessarily believe the two are separate issues. In my opinion, the amount of staffing is directly related to the violent-incident rate. If there are enough people on duty to observe patients' anxiety, then we can take preventive actions and not let the situation reach an explosive level."

Legislators have not completely ignored the subject. For example, since 1993, California has had a law on the books that requires hospitals, home health services, long-term care facilities, and drug and alcohol treatment centers to increase their security.⁴

"The law also mandates staff to be trained in how to identify potentially dangerous circumstances, as well as intervention techniques," added King. "It details how staff are to respond if ever physically assaulted and, of course, the reporting procedures."

In 1995, the Occupational Safety & Health Administration adopted similar guidelines, including recommending management address the emotional and cumulative effects of assaults; the role and responsibility of security officers; and the rights of patients, nurses, and other employees. Though those guidelines are voluntary, many institutions have adopted them.^4,5

However, many nurses believe this still is not enough, including APNA executives. "We took to heart what our members were saying about their fears of abuse on the job, and formed the APNA Task Force on Workplace Violence," said Valentino, who chairs the committee. The task force plans to release its full report at the APNA annual conference, set for October 15 to 18 in Minneapolis, MN.

"It was a huge undertaking to identify the extent of the problem. We have done literature reviews of violent acts in a number of settings, such as inpatient, forensics units, the ED, outpatient facilities, home care, colleges and universities, and other schools, such as elementary and high school. Additionally, the task force will include recommendations of how to curb violence in the workplace and reporting procedures at various levels. If anyone has claims of abuse while on the job, administrators need to take it more seriously than simply report it to a supervisor. They need to investigate it and not let it persist for months and months."

The ENA also has studied the topic and issued a position statement. "It is basically information our members can take to their employers or legislators to use as evidence of the extent of the problem," King said. "That helps drive home the seriousness. Ultimately, we would like to see attacks on healthcare professionals become a felony crime in all states."

Doing your part

Being prepared is perhaps the best defense against violence in the workplace, and that includes taking it upon oneself to initiate proactive policies. "If you want to make a change, research the best practices employed by other facilities, and use that to start a conversation with your management team," Ward suggested. "Ask for educational programs or expert speakers as a way to increase awareness about prevention, as well as how to handle violent situations.

"Besides," she continued, "being able to promote a safe practice environment can help facilities with nurse retention." Valentino concurred. "In the task force's research, we came across studies that suggested first-year nurses cite lateral violence as a reason for dropping out of the work force. We need to mentor those nurses on how to handle such situations, as well as having administrators adopt a zero-tolerance attitude."

"Violence in the workplace is becoming less accepted as the norm," King said, "but it will take every single one of us committed to solving the problem, because anyone can be a victim."

REFERENCES:

1. Lothian, D. "Nurses confront violence on the job." 2007. www.cnn.com/2007/HEALTH/07/11/nurse.violence/index.html (27 June 2008).

2. Biesecker, M. "Nurse beaten at state mental hospital; assault increases staffing concerns." 2008. www.newsobserver.com/front/story/1103764.html (27 June 2008).

3. Derrickson Moore, S. "Healthcare workers are more likely to face violence than any other worker in the service profession." 2008. www.lcsun-news.com/sunlife/ci_9640486 (27 June 2008).

4. Kaufer, S., & Mattman, J. W. "Workplace violence: An employer's guide." 2001. www.workviolence.com/articles/employers_guide.htm (28 June 2008).

5. Emergency Nurses Association. "Emergency Nurses Association position statement: Violence in the emergency care setting." 2006. http://ena.org/about/position/PDFs/45BFF88286AF4167B3C59D4AFE655DC7.pdf (27 June 2008).