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Holding the line against workplace violence

Toon, Molly F., DNP, RN, CPNP-PC; Weaver, Christy, DNP, RN, FNP-C; Frasier, Nora, DNP, MBA, RN, NEA-BC, FACHE; Brown, Kristie L., DNP, RN, ENP-C, FNP-BC

doi: 10.1097/

Abstract: As caregivers, nurses often dismiss violent patient interactions as “just part of the job.” This article addresses this misconception, differentiates between two types of violence present in healthcare settings, and stresses the importance of reporting and evaluating violent acts to plan mitigation strategies.

Violent patient interactions are not “just part of the job.” This article discusses the reasons for this common misperception and interventions that help protect healthcare professionals from violent encounters.

Molly F. Toon and Christy Weaver are assistant professors in the health sciences center school of nursing at Texas Tech University in Lubbock, Tex. Nora Frasier is CNO and vice president of patient care at Methodist Mansfield Medical Center in Mansfield, Tex. Kristie L. Brown is an NP in the Rees-Jones trauma center at Parkland Health & Hospital System in Dallas, Tex.

The authors have disclosed no financial relationships related to this article.



DURING A MORNING SAFETY huddle for hospital leadership, a nurse manager reports on an incident from the previous night: A nurse was struck by an older patient with dementia during her shift, knocking her glasses off. The risk manager asks if the nurse was evaluated for injury in the ED and whether she has completed an occurrence report detailing the incident, and the nurse manager reaches out accordingly. The nurse responds, “No, it was not a big deal. How's the patient? Is she doing okay?”

Unfortunately, scenarios like this are not isolated events. These situations play out routinely on nursing units in healthcare facilities across the country but remain underreported. Nurses are particularly susceptible to potentially violent encounters because caregivers tend to put their patients' welfare before their own, accepting these incidents as “part of the job.”1 This article discusses the reasons for this misperception and offers broad strategies to protect the healthcare staff from potentially violent patient encounters.

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By the numbers

The National Institute for Occupational Safety and Health defines workplace violence as “physically and psychologically damaging actions that occur in the workplace or while on duty.”1 On average, incidents of violence are four times more likely to occur in healthcare settings compared with private industry.1 In a 2014 survey of more than 3,000 nurses, the American Nurses Association found that more than half of nurses reported verbal abuse and 21% had experienced physical assault within the same 12-month period.2

The prevalence of violence against nurses is understated because it is often underreported. This has been consistently demonstrated in multiple studies and represents a persistent barrier to addressing workplace violence for nurses.3-5 According to a 2016 survey by the Texas Center for Nursing Workforce Studies, only 40.5% of nurses said they had reported their most recent experience with workplace violence.3

Reporting these events is vital to provide data that can help clinicians develop an understanding of the patterns and trends of workplace violence, identify commonalities, and implement prevention strategies. Reluctance to do so can be associated with the belief that no one was hurt during the event, that violent acts are part of the job, and that the violent behavior was explainable due to extreme anxiety, confusion, or loss of cognitive faculties.4,5

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Two types of violence

A violent incident can be characterized as either affective or predatory, and perpetrators typically fall into one of those two categories as well.6,7 Understanding the terminology can aid nurses in distinguishing and identifying violent behavior.6-8

Affective violence is an involuntary physical response due to the autonomic arousal of anger or fear. Although it manifests as anger and aggressiveness, it is a response to a perceived threat or danger.6 Many nurses accept affective violence as an inherent part of their job without considering these incidents to be an assault, despite the reality that injuries result from this type of violence. Typically, nurses do not report incidents of affective violence due to a lack of intent to cause harm.3,9-11

Predatory violence is premeditated behavior intended to cause injury. It is cognitively planned without autonomic arousal and characterized by the absence of emotion and threat.7,8 Researchers have described predatory violence as intentional, instrumental, premeditated, and cold-blooded.7,8 Predatory violence is proactive, whereas affective violence is reactive.

Recognizing the differences between these two types of violence can be critical for healthcare professionals, who may be able to defuse the behavior of an affective perpetrator but could endanger themselves trying to reason with a predatory offender.7

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Reporting is key

Nurses have the right to a safe environment and should not normalize workplace violence, regardless of the perpetrator's intent. Identifying both affective and predatory violence will encourage nurses to recognize and report these incidences. Predatory and affective violence each require a decisive response with administrative support, but this requires accurate reporting. Planning for policies, staffing, and workflows to address violence also depends on reporting.

Prevention strategies should be individualized to the two types of violence. Failure to acknowledge and identify violence with a strong response perpetuates underreporting.1,3,12-14 Recognition by nursing staff and leadership will encourage institutional training and policies relevant to the incident in question.

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Recommendations and management

The Joint Commission recently emphasized the need for healthcare organizations to recognize and acknowledge workplace violence, prepare staff to handle violent situations, and efficiently address these incidents after they occur.15 It breaks down management recommendations for responding to workplace violence into four steps:

  • describing and recognizing
  • reporting
  • data and planning
  • response and prevention.

Describing and recognizing an event is the essential first step. Incidents of workplace violence should be defined broadly, and any situation in which a nurse felt unsafe, regardless of harm, should trigger an investigation.15 This inclusiveness should encompass both affective and predatory incidents.

Reporting is facilitated with clear and inclusive definitions. The Joint Commission recommends implementing simple, trusted, and secure reporting systems to remove all barriers to staff reporting and capture, track, and trend every incident of workplace violence.15

Comprehensive reporting makes data gathering and strategic planning possible. Healthcare organizations should review and analyze any contributing factors to determine the appropriate priorities and interventions for each reported incident, including worksite conditions, data trends, quality improvement initiatives, and violence reduction strategies.15

Response and prevention is the ultimate outcome. Healthcare facilities should offer the appropriate follow-up and support to employees following every incidence of workplace violence. The nursing staff should be trained to recognize, de-escalate, and defend against potentially violent encounters. Institutional changes in the physical environment, work practices, and administrative procedures may be needed.15

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Nursing considerations

To minimize risks, nurses must first learn to recognize and differentiate the two types of workplace violence. They may easily spot predatory acts of aggression as workplace violence but fail to regard affective behavior in the same way. Nurses are typically aware that patients engaging in affective violence do not intend to cause harm, so they may not identify the incident as workplace violence.

A 2015 study demonstrated that the intention behind a violent act was a critical factor in how nurses define workplace violence.12 Once workplace violence has been defined and differentiated appropriately within an institution, educating nurses is the next step to improve overall awareness and recognition.

Nursing and organizational leadership can evaluate a facility's existing resources to tailor policies, tools, and training to address workplace violence.

The purpose of reporting and documenting all incidents, including affective violence, is prevention. This lets the healthcare team identify potential triggers leading to violence and implement preventive strategies. As experts in the assessment of individual patients and situations, nurses can help reveal the incidence of workplace violence through accurate and reliable reporting.

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1. Occupational Safety and Health Administration. Guidelines for preventing workplace violence for health care and social services workers. 2016.

2. American Nurses Association. Executive Summary: American Nurses Association health risk appraisal. 2016.—safety/ana-healthriskappraisalsummary_2013-2016.pdf.

3. Texas Center for Nursing Workforce Studies. Workplace violence against nurses in Texas as required by Texas Health and Safety Code Section 105.009. 2016.

4. Arnetz JE, Hamblin L, Ager J, et al Underreporting of workplace violence: comparison of self-report and actual documentation of hospital incidents. Workplace Health Saf. 2015;63(5):200–210.

5. Copeland D, Henry M. Workplace violence and perceptions of safety among emergency department staff members: experiences, expectations, tolerance, reporting, and recommendations. J Trauma Nurs. 2017;24(2):65–77.

6. Muscari ME. When students become dangerous. Medscape. 2012.

7. Tedeschi B. As patients turn violent, doctors and nurses try to protect themselves. STAT. 2015.

8. Meloy JR. Empirical basis and forensic application of affective and predatory violence. Aust N Z J Psychiatry. 2006;40(6–7):539–547.

9. Hartley D. NIOSH science blog: violence in healthcare. Centers for Disease Control and Prevention. 2015.

10. Phillips S. Countering workplace aggression: an urban tertiary care institutional exemplar. Nurs Adm Q. 2007;31(3):209–218.

11. Pierce CM. Barriers to nurses reporting workplace violence in the emergency department. Rhode Island College: James P. Adams Library Digital Commons. 2015.

12. Blando J, Ridenour M, Hartley D, Casteel C. Barriers to effective implementation of programs for the prevention of workplace violence in hospitals. Online J Issues Nurs. 2015;20(1).

13. Gacki-Smith J, Juarez AM, Boyett L, Homeyer C, Robinson L, MacLean SL. Violence against nurses working in US emergency departments. J Nurs Adm. 2009;39(7-8):340–349.

14. Gallant-Roman MA. Strategies and tools to reduce workplace violence. AAOHN J. 2008;56(11):449–454.

15. The Joint Commission. Sentinel event alert: physical and verbal violence against health care workers. 2018.

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1. American Nurses Association. Workplace violence. 2017.

2. American Organization of Nurse Executives; Emergency Nurses Association. Toolkit for mitigating violence in the workplace.

3. Centers for Disease Control and Prevention. The National Institute for Occupational Safety and Health. Occupational violence. 2018.

4. Occupational Safety and Health Administration. Workplace violence. US Department of Labor. 2017.

5. The Joint Commission. Workplace violence prevention resources for health care. 2018.


affective violence; physical assault; predatory violence; verbal abuse; workplace violence

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