PICTURE A BUSY ED full of patients, some with medical illnesses or traumatic injuries and some with psychiatric illnesses. A nursing assistant is walking around the corner quickly, engrossed in her task, when a psychiatric patient suddenly charges, punching her in the face. Fortunately, her coworkers are quick to subdue the patient, but in the resulting melee, a nurse is severely bitten. The patient is placed in restraints and awaits involuntary commitment while the ED nurse and nursing assistant are treated for their injuries.
This article describes the impact and causes of workplace violence in healthcare. It also covers preventive tactics and long-term solutions to this ongoing problem. (See Setting out definitions.)
Scope of the problem
Unfortunately, incidents like the one described here occur much too often, both in and out of hospitals. Violent behavior isn't limited to patients with mental illnesses—all other types of patients as well as family members are assaulting healthcare workers. Besides EDs and psychiatric units, other areas in which staff is at an increased risk for violence include ICUs; pediatric, obstetric, and neonatal units; and long-term-care facilities.1
A 2001 study by the U.S. Department of Justice stated that the average nonfatal violent crime rate for all occupations was 12.6 per 1,000 workers compared with 21.9 per 1,000 nurses. Forty-eight percent of all nonfatal injuries happened to nurses or assistive personnel.2
A 2006 survey commissioned by the Emergency Nurses Association (ENA) of 1,000 of its members showed that 86% had been the victim of workplace violence in the previous 3 years.3
Outcomes of violence
Violent acts against healthcare workers have a profound impact on our profession. In the ENA study, over half of survey participants reported that they didn't feel safe from workplace violence in the ED and didn't feel prepared to handle violent incidents.4
In this same survey, 74% of the participants reported their employer had no protocol for responding to episodes of workplace violence; in 44.9% of cases, no action was ever taken against the perpetrator of the violent act.5
The participants in the ENA study named eight barriers to reporting, including a fear of retaliation from hospital staff, a lack of physical injury, and the inconvenience of reporting. More surprising was workers' concern that reporting would adversely affect their customer service scores, or the fact that many accepted violence as just a part of the job. Other factors included ambiguous reporting policies, lack of support from administration, and the idea that reporting was a sign of incompetence or weakness.5
The lack of action and reporting speaks to the apparent acceptance of this behavior. Changing this paradigm will be a major step toward resolving this issue.
The ENA study noted that hospitals with no policy for patient and visitor violence had a physical violence rate of 18% compared with a violence rate of 8% in facilities that had adopted a zero-tolerance policy.5 This discrepancy gives credence to the broken windows theory, a criminal justice theory that tolerance of minor crimes creates an environment conducive to more serious crimes.6
In 2001, the American Nurses Association adopted a bill of rights that said nurses have a right to work in an environment safe for themselves and their patients. In 2004, both the National Institute for Occupational Safety and Health (NIOSH) and Occupational Safety and Health Administration (OSHA) developed national mandates stating that healthcare organizations have a duty to provide safe work environments.7 The Joint Commission also has a leadership standard stating that institutions must create and implement a process for managing behavior that undermines a culture of safety.8 Institutional leadership and other professional organizations need to adopt policies that state it's no longer acceptable to be assaulted while at work.
Understanding the causes
So what's causing this epidemic in violence directed toward healthcare workers? One significant factor may be societal changes that have decreased family and community support.9 The economy may be another cause—many states have closed mental health hospitals and reduced funding for addiction programs. These closures have increased the number of patients with mental health and substance abuse issues who are seen in EDs, from 1.6 million in 2005 to over 2 million in 2008.10
The ENA study showed that patients and their relatives are the perpetrators of nearly all of these violent incidents and that the patient's room is the most common site. These are some of the causes of these violent acts:
- more mental health patients, including those with Alzheimer disease or dementia
- patients exhibiting drug-seeking behavior
- patients or visitors under the influence of drugs or alcohol
- ED crowding
- longer waiting times and holding or boarding patients in the ED
- shortage of nurses
- misconceptions about staff behavior or belief that staff doesn't care
- visitor policy is lacking or poorly enforced.5
In 2002, NIOSH published additional risk factors that contribute to the likelihood of an act of workplace violence. A history of assaultive behavior is a highly predictive factor in a patient or visitor. Other causes identified include agitation, anger, disorganized behavior, and alcohol or illicit drug use.11 (See What are the risk factors for violence?)
Understaffing also increases the risk of violence, especially during times of increased unit activity such as meal times or visiting hours. A particular risk factor is a staff member working alone or in isolation; the presence of a coworker is a potential deterrent.
Nurses need to develop a greater awareness of our risk and the potential for violence. Start by considering OSHA's “Guidelines for Preventing Workplace Violence for Health Care and Social Service Workers.”12
Management needs to commit to creating an environment that's not conducive to workplace violence. Hospital leaders must develop an awareness of the problem and then adopt a zero-tolerance policy.
Employees need to be involved on committees to develop polices to create a safe workplace. This involvement creates greater awareness of the issue and helps change the culture of acceptance of violence. Staff involvement also helps management understand the workplace environment and the particular threats encountered by staff.
A worksite analysis is an important step in evaluating an institution's risks. This analysis leads to both hazard prevention and control.
A comprehensive organizational violence prevention program needs three components:
- A reporting and documentation system must be in place to capture and trend data on violent incidents.
- Policy should note specific strategies to institute in the event of an incident.
- Perhaps most important, postevent incident management and support for the staff impacted by the violent event are needed.9
Other recommended practices include improving employee identification systems and access control. Hospitals need to improve facility design for better security and management of at-risk groups. The creation of behavioral health areas in EDs is one example. Other innovations include the development of inpatient psychiatric critical care areas, which are better resourced, equipped, and educated to handle behaviorally unstable patients compared with typical inpatient psychiatric units.9
Resources and new roles are also important considerations. A family advocate program can provide staff to intervene in a behavioral crisis when hospital staff must focus on clinical care for the patient.
Raising nurses' awareness
Education can improve nurses' ability to recognize a dangerous situation and respond appropriately. Courses developed by the Crisis Prevention Institute, among others, are developed to improve nurses' skills in communication, de-escalation techniques, and self-protection if an encounter turns violent.
Anticipation is the most effective strategy because aggression rarely occurs without warning signs. Patients who are tense or anxious are potentially violent. Escalating verbal abuse or physical agitation, such as pacing, are also warning signs.13
Any situation in which a patient or family member feels helpless or trapped is cause for heightened awareness. It should be routine practice to always leave a safe distance between yourself and the patient, especially when you feel threatened. Allow a personal space of 4 to 6 ft (1 to 2 m), or at least further than two steps or one arm's distance between yourself and the other person.14 Be aware of the nearest exit, and don't let the person get between you and the exit.
Assault is a crime
Although assault is against the law, cases of assault on healthcare workers are rarely aggressively prosecuted. To address this problem, many nursing, physician, and hospital groups have worked to introduce and garner support for legislation making assault on healthcare workers a felony. Although a new law won't address the root causes of violence, it might provide a deterrent. Only 26 states have laws directing employers to have comprehensive workplace programs to prevent violence, and only 11 states have laws for tougher penalties for assaults on nurses.10 As a profession and a country, we must address the health policy gaps that lead to some patients' frustrations.
The incident presented in this article was the impetus for dramatic improvement in the author's facility. Over time, staff received better education and learned how their own behaviors could either lead to or mitigate these situations. The ED was redesigned to create a more effective and secure area for potentially violent patients, and resources were provided for the level of care needed.
Nurses must refuse to accept the status quo. Our profession needs to mobilize for action by working actively in our hospitals and communities to institute best practices. We should be clear that allowing healthcare workers to be victims of violence isn't acceptable. We don't need to be hurt so that we can care.
Setting out definitions
- Workplace violence is considered to be any violent act, including physical assaults or threats of assault, directed toward people at work or on duty. These assaults or threats include physical and psychological violence as well as abuse, bullying, and racial or sexual harassment.6
- Verbal abuse includes being called names, being threatened or intimidated, or being the recipient of sexual innuendo.
- Physical abuse includes being pushed, hit, scratched, or kicked.
The University of Iowa Injury Prevention Center developed a four-point model to help understand workplace violence:
- Type I is workplace violence with criminal intent.
- Type II includes violence committed by clients or customers.
- Type III deals with worker-on-worker violence.
- Type IV refers to violent acts based on personal relationships.6
This article is primarily concerned with Type II acts, although Type III and IV are also encountered.
What are the risk factors for violence?
The risk factors for violence vary from hospital to hospital depending on location, size, and type of care. Common risk factors for hospital violence include the following:
- working directly with volatile people, especially if they're under the influence of drugs or alcohol or have a history of violence or certain psychotic diagnoses
- working when understaffed—especially during meal times and visiting hours
- transporting patients
- long waits for service
- overcrowded, uncomfortable waiting rooms
- working alone
- poor environmental design
- inadequate security
- lack of staff training and policies for preventing and managing crises with potentially volatile patients
- drug and alcohol abuse
- access to firearms
- unrestricted movement of the public
- poorly lit corridors, rooms, parking lots, and other areas.
Source: CDC. NIOSH Publications and Products. DHHS (NIOSH) Publication Number 2002-101. Violence NIOSH. Violence Occupational Hazards in Hospitals. 2002. http://www.cdc.gov/niosh/docs/2002-101/.