Workplace violence: causes, prevention, and organizational impact

¶ … Workplace violence and nursing: An overlooked epidemic

Nurses often work under high-stress conditions. They deal with people who are sick and in pain. Physical and mental illnesses, the side effects of medications, and other factors can compromise a patient's judgment and ability to control his or her own actions. In many environments, such as the emergency room, nurses may even have to cope with the aftermath of crime, including taking care of possible criminals as well as crime victims. "Agitated clients in mental health facilities and the emergency department, demented elderly patients in medical and geriatric wards, nursing homes and rehabilitation centers, and any patient with a history of assault in mental health, hospital care, and community health are common sources of verbal and physical violence against nurses and other health care providers" (McPhaul & Lipscomb 2004). According to the American Nursing Association's 2009 statement on the subject of "Workplace violence" the ANA is striving to protect nurses from occupationally-related violence, and also seeks more specific guidelines from the federal Occupational Safety and Health Administration (OSHA) to set enforceable legal standards regarding on-site violence.

OSHA defines workplace violence simply as "violent acts (including physical assaults and threats of assault) directed toward persons at work or on duty" (Workplace violence, 2001, OSHA). These acts could include both physical and psychological actions, such as physical abuse, bullying, and harassment. However, while OSHA condemns workplace violence, at present, within the guidelines of the OSHA "there are currently no specific standards" setting the standard for what constitutes workplace violence," although employers are required to "furnish to each of his employees employment and a place of employment which are free from recognized hazards that are causing or are likely to cause death or serious physical harm to his employees" and to "comply with occupational safety and health standards" (OSHA, 2010). In practice, enforcing OSHA standards in healthcare settings has often focused upon ensuring that workers are not exposed to disease-related risks or excess strain from ergonomic issues, such as lifting heavy patients, as these types of issues do have specific regulations tied to their enforcement.

Despite the lack of a formal, legal definition of workplace violence, the risk of physical violence for healthcare workers is very real: A Department of Justice National Crime Victimization Survey (NCVS) for the years 1993 through 1999 found that the healthcare field led all industry sectors in nonfatal workplace assaults. A 2000 study found that 48% "of all nonfatal injuries from violent acts against workers occurred in the health care sector," with nurses, nurse's aides and orderlies suffering the most (McPhaul & Lipscomb 2004). Assaults, bruises, lacerations, broken bones and concussions were reported as the most common types of injuries. More than 30% of nurses reported having been the victims of workplace violence in another study, and only 5% of these were ER nurses or in other high-risk specialties (Carroll 1998). Most had been assaulted by patients.

The risk of assault is even higher for those individuals who work in emergency rooms: "one Florida study found that 100% of emergency department nurses experience verbal threats and 82% reported being physically assaulted (n=86, one hospital)" while a multi-hospital Canadian survey found "39.9% of emergency nurses reported being threatened with assault and 21.9% reported physical assaults" (McPhaul & Lipscomb 2004). The results of a 2009 Emergency Nurses Association survey "found that more than 50% of ER nurses had experienced violence by patients on the job and more than 25% had experienced 20 or more violent incidents in the past three years. Research showed long wait times, a shortage of nurses, drug and alcohol use by patients, and treatment of psychiatric patients all contributed to violence in the ER" (Workplace violence, 2009, ANA).

This prevalence of violence is deleterious to the health of patients as well as staff. In an already over-burdened workforce, the "median number of days away from work from assault or violent act is five days, with almost a quarter of these injuries resulting in longer than 20 days away from work" (McPhaul & Lipscomb 2004). Workers who are assaulted can experience profound and long-lasting psychological trauma. If violence persists, they may seek to leave the profession, or areas of the profession where there is an especially acute need for care, such as ER work. The "financial loss resulting from insurance claims, lost productivity, legal expenses, property damage, and possible staff replacement costs" due to violence is also considerable (Workplace violence, 2009, ANA).

Ironically, understaffing is a critical aspect of the reason that there is workplace violence: tired workers are apt to be less vigilant, and there are also fewer 'hands no deck' to restrain violent patients. A further facilitator of workplace violence is that more and more nurses are providing services within clients' homes. In such situations, the nurse is almost always unsupervised and unprotected. Less oversight can lead to greater risk of violence. 38% of 364 public health field-workers in one study said they experienced violent events during their employment, a total of 611 events (McPhaul & Lipscomb 2004). "Transporting patients, long waits for service, inadequate security, poor environmental design and unrestricted movement of the public are associated with increased risk of assault in hospitals and may be significant factors in social services workplaces as well. Finally, lack of staff training and the absence of violence prevention programming are associated with elevated risk of assault in hospitals" (McPhaul & Lipscomb 2004).

As crime grows more common, staff members are apt to see it as less remarkable. Amongst nurses themselves, there can create a sense that an increased level of physical risk is acceptable, along the lines of 'broken windows' theory which suggests that "ignoring or tolerating" even "low-level crime creates an environment conducive to more serious crime…when verbal abuse, threats of assault and low level daily violence are tolerated in health care environments more serious forms of violence will follow" (McPhaul & Lipscomb 2004). There is growing resignation within the profession that violence "is part of the job" (McPhaul & Lipscomb 2004). Few environments provide widespread training in how to guard against violence, how to deal with it, and how to spot it before it spirals out of control. Additional protocols which can prove useful to include are the tracking of large and small abuses, to see if preventative measures are adequate.