This paper will explore the incidences of violence that occur in the nursing environment and how it is affecting nurses both physically and mentally. Nurses and healthcare professionals have the highest rate of workplace violence. This paper will show the different types of workplace violence towards nurses as well as interventions that are being put into place to help alleviate these heinous acts.
Work place violence comes in all shapes and sizes. Sadly, it is found in some way, shape or form in almost every career field. In the nursing field violence is all too common. This will focus on the violence toward nurses. Aggression can be defined as behavior that harms regardless of the intention of the aggressor (Edwards, 2014). Aggression can be physical or verbal. Work place violence can negatively affect a healthcare worker whether harm is actually sustained, or the intention is clear.
Being the target of work place violence has been found to be associated with anxiety, fear, guilt, sleep disturbances, burnout, poor self-rated health or dissatisfaction toward work. Longitudinal studies have shown that the relationship between workplace aggression and the wellbeing of employees seems bidirectional. Those who experience work place violence are more likely to report occupational stress. As a result, occupational stresses are at a higher risk of workplace aggression. In situations in which a patient, family member, or health care team member poses a real or perceived threat to the physical or emotional well being of a nurse, the nurse has to justify taking actions for self-preservation (Dermenchyan, 2018). With this being said the overall care of the patient or other patient’s is compromised. The nurse is concerned with his/her own health and well being that there may be a disconnect to the other care. Causing burn out to happen faster.
67% of all nonfatal workplace violence injuries occur in healthcare, but healthcare represents only 11.5% of the U.S. workforce. (Locke, 2018). These actions are all to common in the United States and nurses are frequently the victims of theses “crimes”. They are minimized when they should be publicized, and the seriousness needs to be shown to the world to put a stop to it. Twenty-five percent of healthcare employees have been physically assaulted at work by a patient or patient’s family members while on the job (Trossman, 2018).
Many issues unrelated to mental health are causing the rise of violence. These issues include emergency room wait times, domestic disputes, an opioid epidemic that’s bringing desperate patients to hospitals for drugs or addiction treatment, and by a general a shortage of beds for behavioral health, and even nursing shortage itself. Nurses are being asked to care for more patients then they should while on specialty floors. A PCU nurse should have no more than four patients in a shift and yet many hospitals are assigning these nurses with five patients. This issues in turns causes the wait times while on the floor to increase and the nurses to be backed up and the patients and the families become irate with the care of their family members causing outbursts towards the staff and in particular the nurses.
According to The National Institute for Occupational Safety and Health, there are four types of workplace violence. Type I is Criminal Intent. This is a result of criminal activity that is being committed and the aggressor has no legitimate relationship to the person or the workplace. Type I also includes theft or property damage. Type II involves a customer and client relationship. The offender is a customer or client at the workplace and becomes violent while being served by the worker. An example of Type II occurs when a patient, family, or visitor assault a healthcare worker. An example of type II is when a patient hits while they are trying to assist them with hygiene care or feeding assistance.
Type III involves a worker-on-worker relationship. Employees or past employees of the workplace are the offender. Type III includes verbal abuse, bullying, or physical assault from a co-worker. An example of type III is when a nurse threatens to lay hands on another nurse on their person because assignment request was denied. Type IV involves a personal relationship. The offender usually has a personal relationship with an employee. Type IV includes domestic violence that spills over into the workplace. An example of type IV would be when an estranged spouse shows up at hospital to violently confront nurse for no allowing them to be able to see their child or argue about child support.
The increasing incidence of workplace violence that nurses and healthcare workers encounter can lead to a hostile workplace environment. This hostile workplace environment can influence a nurse to leave a critical bedside setting for a calmer setting such as an outpatient or community practice. It means that hospitals are losing some of their best and brightest critical care nurses because of workplace violence. According to the 2000 Bureau of Labor Statistics, ‘Healthcare workers suffer four times more non-fatal assaults than the private sector’. NIOSH 2002 findings state that healthcare workers are more likely to be attacked at work than police officers or prison guards.
The American Association of Colleges in Nursing reveals that 80-97% Health Care Workers (HCWs) experience verbal, 49% say abuse affects their safe handling of decision-making, nurses are as frequently disruptive to nurses as physicians are to nurses, and 35-60% new nurse graduates leave first job related to lack of workplace social support such as bullying. It seems that type II workplace violence is the most prevalent in healthcare settings. A 2012 survey reveals that 40% of reportable most serious work place violence is due to interactions with patients and visitors. It also reveals that staff and faculty work place violence toward colleagues equals 16.3%. However, they also found that prevention strategies and zero tolerance policies can reduce occurrence of abusive incidents.
The lateral threat of nurse to nurse aggression and violence also needs to be addressed. The most frequent source of verbal violence against nurses were co-workers, followed by patients, and physicians (Kvas, 2015). This can be avoided by being civilized with everyone during everyday situations. Nurses also need to hold themselves and each other accountable for unacceptable behavior. Forming a task force or committee to establish an education plan to address lateral violence can aid in decreasing work place aggression. Lateral violence will end only when the work environment changes to promote positive bystander action to fully address bullying. The focus moves from one on one bully-victim interaction to proactive trained bystanders working as a group using three forms of action to greatly reduce or eliminate bullying altogether. A decrease in lateral violence has been shown to improve morale, teamwork, satisfaction, and an increase in reporting of incidents. Staff continue to look to leadership to address these issues when they are occurring.
It is important to identify the four types of work place violence and to implement effective measures in order to de-escalate an aggressive situation. For example, it is important to identify and use a system to document and report all types of workplace violence events such as the Veritas system and the Tennessee First Injury Report. This should be performed every time any person physically touches you without your consent and even without causing injury. For example, a report should be made when a patient spits on a nurse or when a co-worker grabs a nurse by the shoulders in a forceful way (Gale, 2016).
With all of the types of violence and there needs to a prevention plan to help eliminate the bullying and violence in the healthcare setting. There are four steps to alleviating fears and actions of bullying. Step one: recognize the bullying. The charge nurse or leader needs to be notified. They should be informed of both the physical and mental effects and the impact on the workplace environment and the productivity of the nurse. Step two: Intervene, of the steps this is the most difficult part, especially on the leader. To successfully intervene the leader has to make an effort to stop all issues right at the source. Step three: Stop rumors, when there are rumors about the target floating around this allows for bystanders to have opinions and possibly not intervene. So, these need to be stopped and the leader needs to have a connection into the rumor mill and be to put an end to the unfair and negative rumors. Finally, Step four: Hold leaders and organizations accountable, this is to make a commitment to end the workplace bullying. The higher ups need to create and implement anti-bullying policies. This will grow to the larger vision on a safer workplace (Hellebrand, 2018).
With all the bullying there is fear that grows in the targeted party. Fear is an unpleasant and often strong emotion caused by anticipation or awareness of danger. (Hellebrand, 2018). Even with the prevention program that are in place the fear is so real that some people that are bullied won’t come forward and start these steps in fear of repercussions from the intimidator or management. I have found that many articles that I read showed the ongoing zero tolerance is being put in place placed to put an end to the violence towards nurses and even violence towards patients from nurses. Even with these zero tolerance policies, nurses need to develop the mind frame that work place violence is not acceptable and is not “part of the job”.
There are many effective measures to prevent patient/visitor workplace violence towards nurses. It is important to provide all nurses with training in verbal and non-verbal skills to de-escalate a situation. This can be accomplished through certified training such as the national Handle with Care or other effective education frameworks. Another way to prevent work place violence is to determine the potential need to add psychiatric mental healthcare to augment medical care provision in general hospital units that are admitting and caring for actual psychiatric patients due to psychiatric bed shortage. This has been an urgent and growing need in Middle Tennessee since the fall of 2015 and has also been reported throughout the country both in Texas and California (Gale, 2016). Hospitals have also debuted technologies and launched awareness campaigns. States have proposed laws requiring workplaces, including in healthcare, to establish anti-violence protocols. Unions are striving for reduced nurse-to-patient ratios.
The risk of violence increases when nurse-to-patient ratios fall below a critical level. Patients sometimes resort to violence to catch nurses’ attention. As stated prior the more patients that nurses and other providers must care for, the less time they can spend with each patient. The more overworked they become, the harder it is for them to catch warning signs of possible violent behavior. Some hospitals try to cut costs by hiring fewer care providers. Other facilities have stressful environments that result in nurses’ burning out and leaving. Still hospitals struggle to hire nurses because of geographical issues because the hospitals are in a rural area and might have a lack of nursing graduates. It appears that increasing awareness and implementing hospital protocols might not be enough. Stricter regulatory standards and enforcement might also be necessary and focusing on education of the zero policy procedures as they develop with time.
Since 1996, OSHA has offered voluntary guidelines for preventing workplace violence for healthcare and social service workers. However, OSHA can’t enforce those guidelines or require employers to implement prevention programs. All OSHA can do is cite employers for violence in healthcare settings under the Occupational Safety and Health Act’s general duty clause, which requires employers to provide a workplace free from hazards. But OSHA inspectors must meet a high burden of proof in order to issue citations. Even if OSHA does issue citations, OSHA doesn’t require employers to take corrective action or require inspectors to follow up (Whitman, 2017).
In the absence of federal rules, nearly a dozen states have enacted laws requiring healthcare employers to create plans or programs to protect workers from violence at work. Often, violent incidents are the trigger that prompts such legislation. These laws vary considerably in substance and scope. Despite the widespread recognition that violence in healthcare workplaces as a growing problem, there’s little agreement on how best to resolve these issues. An April 2016 editorial in the New England Journal of Medicine pointed out that most research is geared toward quantifying the problem rather than studying how to solve it.
In conclusion, there is a rise in work place violence in the health care field as apposed to other career fields. Patient/visitor workplace violence towards nurses is the most common type followed by lateral nurse to nurse violence and aggression. There have been practical measures made to resolve work place violence with little improvement. This includes certified training, forming a committee to mediate aggressive actions, technology, awareness campaigns, legislation, and limiting patient load. There has been evidence of success. However, lack of universal standards to prevent aggression has created a barrier to have a universal protocol to combat work place violence. Punishment and criminal laws varies from state to state. Some states do not include protection for nurses. Awareness of the negative effects work place violence has on nurses needs to be a priority in a national level. Lateral aggression of nurse to nurse violence also needs to be in the front of the topic.
It all starts with treating peers with mutual respect and obtaining skills to positively resolve conflict. Further actions are needed in order to further decrease work place violence against nurses. Nursing is a privileged field with compassion and care that can greatly influence patients to a quick road to recovery. Nurses need to be their own advocate as well in reporting and fighting for themselves. Protecting what they believe in, keeping themselves safe to keep the care of their patient’s safe. It is a spinning wheel of actions and taking one action and breaking it, IE: violence towards the caregiver/ nurse can break the whole wheel and the will to care for others, the will to care for themselves. If the healthcare field is plagued with fear and aggression; we will lose the world’s best and brightest nurses because of feeling neglected and burnt out. The violence must stop. Human beings need to stop and care for one another. Without support and caring in the world there is just pain and suffering. Violence needs to come to an end. We are living longer and being here in this time and place need kindness and support. All people need to be picked up and supported.
