Ideally, the workplace should be free of violent threats or actions and staff should feel safe while at work. Workplace violence has been defined by the National Institute for Occupational Health and Safety (NIOSH) as an act of aggression directed towards persons at work or on duty and ranges from offensive or threatening language to homicide. Workplace violence has gained recognition as a distinct category of violent crime that requires specific responses from employees, law enforcement and the community.
Medical institutions are particularly vulnerable to violence because of the 24-hour accessibility to the public, the possible lack of adequately trained, armed or visible security and an overall stressful environment. The National Crime Victimization Survey (1993-1999) found that the average annual rate for non fatal violent crime was 21. 9% per 1000 workers for nurses compared with only 12. 6% per 1000 workers for all occupations. The environment of medical institutions and the inherent condition of the patient’s being cared for can fuel the emotional tension between staff, patients and visitors.
In the health care industry, it is difficult to get accurate incidence statistics because violence is often underreported. There are multiple reasons why an employee would fail to report a threatening or injurious action, directly affecting his or her personal safety and well being. Because medical services are perceived to be a public entitlement, nurses are often empathetic to the frustration and vulnerability of the patients and visitors and violence is frequently considered to be “just part of the job”.
ENA and other health care professional organizations and unions are advocating for federal standards and regulations that require health care institutions to practice effective violence prevention and response. The Occupational Safety and Health Administration has published the Guidelines for Preventing Workplace Violence for Health Care and Social Service Workers which includes policy recommendations and practical corrective measures to help prevent and mitigate the effects of workplace violence. The guidelines are voluntary.
Joint Commission has always recognized the importance of providing a safe environment for the patient. A recent Sentinel Event Alert was issued by the Joint Commission identifying the rising rate of health care institutions and offering a list of thirteen suggested actions that organizations can take to prevent violent crimes in their healthcare facilities. With this in mind health care workers and their professional organizations believe that safe practices should not be voluntary guidelines or recommendations.
In 2009, ENA published a study entitled “Violence Against Nurses Working in US Emergency Departments”. In an effort to better understand the strategies necessary to effectively address this problem and facilitate a safer workplace, their study focused on investigating nurses’ experiences and perceptions of violence from patients and visitors in emergency departments in the US. A total of 3,465 emergency nurses who were ENA members participated in this cross-sectional study. The 69-question survey was conducted online for one month in the spring of 2007.
More than half of the nurses surveyed for Violence Against Nurses Working in U. S. Emergency Departments, cited one or more of the following as precipitating factors when they experienced abuse: patients or visitors under the influence of alcohol or illicit drugs; psychiatric patients being treated in the emergency department; crowding; prolonged wait times; and shortage of emergency department nurses. Research indicates that such situations can cause frustration and feelings of vulnerability, which may result in physical and verbal abuse against emergency department staff.
More than two in three (67 percent) of emergency nurses rated their perception of safety in the emergency department at five or lower on a ten point scale and one in three said she or he had considered leaving her or his department or emergency nursing altogether because of the violence. Reports of violence were lowest among nurses in pediatric emergency departments and highest among nurses who worked night shifts and on weekends. Female emergency nurses were more likely than their male colleagues to indicate having experienced workplace violence.
The purpose of the EDVS study is to examine: • The extent to which various types of workplace violence from patients and visitors occur toward emergency nurses • The extent of under-reporting of workplace violence toward emergency nurses from patients and visitors • The current reporting mechanisms, if any, for violence toward emergency nurses • The current processes, if any, used to respond to violence toward emergency nurses • Trends in violence toward emergency nurses over time
The EDVS study is a longitudinal trend study that utilizes a cross-sectional online survey administered quarterly Survey includes questions about workplace violence experienced during the previous seven days Every week, in the United States, between eight and 13 percent of emergency department nurses are victims of physical violence, according to the EDVS study findings released from the first year of data collection. More than half the nurses (a mean of 54. 8 percent) surveyed by ENA reported experiencing physical or verbal abuse at work in the last seven days.
The EDVS Study also found that 15 percent of the nurses who reported experiencing physical violence said they sustained a physical injury as a result of the incident and in almost half of the cases (44. 9 percent), no action was taken against the perpetrator. In ENA’s position statement, Violence in the Emergency Care Setting, it is asserted that health care organizations “must take preventive measures to circumvent workplace violence and ensure the safety of all health care workers, their patients and visitors”.
The position statement outlines the role and responsibilities of emergency nurses in preventing, responding to and reporting workplace violence. Workplace violence unfolds in three major areas. Unlike some situations or hazards that can be prevented completely, emergency department workplace violence initiatives need to be structured to have a multifocal impact because regardless of how secure an emergency department may appear, an occurrence is likely to occur over time. While instituting zero tolerance for the occurrence of violent incidents, these occurrences can be effectively prevented and reduced.
In addition, staff must also be prepared to contain when they do occur and report so that review can lead to proactive interventions and a safer future environment. This slide depicts the phases of violent behavior. Strategic initiatives should be directed at the pre-assault phase, at de-escalation and prevention and the assault phase for containment and response. One can also add a post-assault phase for the purposes of identifying policies and procedures necessary within the institution for documenting, reporting and dealing with the perpetrator and victims after an incident has occurred.
It is also important to recognize that there is a spiraling effect of violence and it is important to be able to identify and effectively interrupt the sequence before the consequences become life threatening. The tipping point, as shown by this graphic, is when the behavior is no longer ambiguous, and is clearly intentional. Many nurses don’t consider verbal abuse as “violent” behavior. As this slide depicts, besides the obvious emotional toll that verbal abuse can take on employees, verbal abuse is a clear warning sign of escalation of intent to harm physically and should be taken seriously.
Verbal abuse is not part of anyone’s job and each employee should have a personal “zero tolerance” policy for this type of violence Review the slide. This slide explains that prevention is focused on eliminating violent occurrences in the pre-assault phase. Measures would include de-escalation techniques or implementation of a de-escalation team, identification of high risk patients, environmental measures to increase awareness of high risk behaviors and increase presence of security on site and working with staff to acknowledge and understand the common goal of intolerance for any verbal or physical abuse.
The response phase refers to quick and effective containment of a violent occurrence to minimize the harm caused and to keep patients, visitors and staff safe. Some measures would include personal defense training for staff, instituting a Violence Rapid Response Team, physically containing a patient in a “safe room”, initiating a lockdown of the unit and defining a mechanism for quick response of local law enforcement Also part of a response strategy is defying the culture of some emergency nurses that promotes certain violent acts as “part of the job”.
Staff perceptions are sometimes the most difficult to change but understanding where the staff stands on the issue of workplace violence and working towards each staff member having zero tolerance for verbal and physical abuse. 100% compliance with responding, not ignoring, incidents within clear departmental and institutional guidelines will promote the culture of safety in the medical community and send a message to would-be assailants.
These measures need the full support of hospital and specifically emergency department administration. Studies have shown that 50% if verbal and physical assault incidents perpetrated by patients against nurses were never reported in writing. In addition to perceiving that the incidents were part of the job and that reporting would be unhelpful, the nurses indicated that a lack of evidence of physical injury as well as empathy for the patient’s and family member’s anger as reasons for not filing a report.
Nurses have the right AND responsibility to report incidents of violence and abuse to their employer without fear of reprisal as well as the right to report incidents to local law enforcement authorities and pursue legal action; health care organizations should encourage and support nurses in reporting incidents of violence and abuse (ENA position statement)Consistent reporting needs to be encouraged as “it doesn’t exist” if it is not reported. Reporting works as a deterrent…when the word is out that people who commit violence in the medical setting will be taken to court, it does cut down on the violence References 1.
Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health (2002). Violence: occupational hazards in hospitals.
Retrieved from
http://www. cdc. gov/niosh/pdfs/2002-101. pdf 2. US Department of Labor, Occupational Safety and Health Administration. (2004). Guidelines for preventing workplace violence for health care & social service workers. Retrieved from http://www. osha. gov/Publications/OSHA3148/osha3148. html 3. Emergency Nurses Association. (2010). Emergency Department Violence Surveillance Study. Des Plaines, IL: Author. Retrieved from http://www. ena. org/IENR/Pages/WorkplaceViolence. aspx . Emergency Nurses Association. (2010). Position Statement: Violence in the emergency care setting. Des Plaines, IL: Author. Retrieved from http://www. ena. org/about/position/position/ 5. The Joint Commission. (2010). Sentinel event alert, issue 45: Preventing violence in the health care setting. Retrieved from http://www. jointcommission. org/sentinel_event_alert_issue_45_preventing violence_in_the_health_care_setting_/ 6. Gacki-Smith, J. , Juarez, A. M. , Boyett, L. , Homeyer, C. , Robinson, L. , & MacLean, S. (2009). Violence against nurses working in US emergency departments. The Journal of Nursing Administration, 39, 340-348.
