This paper examines workplace violence directed at nurses by patients and their families, a critically underreported issue in contemporary nursing. It defines the scope of such violence — ranging from physical assault to verbal abuse — and analyzes its significance to nursing practice, including effects on nurse wellbeing, staffing, and professional retention. The paper also considers how patient-initiated violence threatens patient safety through distracted care, medical errors, and a disrupted care environment. Finally, it proposes measures to reduce violence, including aggression management training, rapid response security teams, and federal policy frameworks requiring institutional prevention programs.
Violence from patients towards nurses is one of the least discussed contemporary nursing issues. As Stevenson, Jack, O'Mara, and LeGris (2015, p. 32) observe, "registered nurses (RNs), compared to other healthcare providers, are at a higher risk of experiencing violence in the workplace that is initiated by patients and families." In essence, violence from patients towards nurses includes any act of aggression initiated by the patient and/or their relatives and friends and directed at the nurse. Acts of aggression in this context include, but are not limited to, grabbing, scratching, hitting, and in some cases verbally threatening the nurse in an intimidating manner. In some extreme instances, nurses have been killed by those they were attempting to care for. Patients likely to become violent towards nurses include those with mental health issues and those under the influence of drugs or alcohol (Ramacciati, Ceccagnoli, Addey, Lumini, & Rasero, 2016, p. 23).
According to Roche, Diers, Duffield, and Catling-Paull (2010, p. 14), the fact that nurses offer front-line service and remain in close proximity to patients makes them prime "targets for interpersonal violence." The services nurses provide in the healthcare setting are largely hands-on. This proximity is necessary not only for administering medications but also for monitoring patient conditions. Nurses also serve as an important link between patients and doctors and maintain key records relating to patient health and progress. The relevance of nurses in the healthcare setting cannot, therefore, be overstated. Anything that disrupts the effective functioning of nurses in this setting is a threat to the smooth functioning of the entire health system. As Stene, Larson, Levy, and Dohlman (2015, p. 114) point out, most violence from patients towards nurses occurs in the emergency room, where violent altercations can disrupt the flow of activities and effectively disadvantage other patients.
Nurses contend with a wide range of challenges in the discharge of their duties. Common challenges include working long hours, managing the anguish of family members following the death of a loved one, and ensuring that patients adhere to their treatment regimens even when resistant. Workplace violence is yet another burden nurses must carry. As Stevenson, Jack, O'Mara, and LeGris (2015, p. 37) note, violence from patients towards nurses takes a toll on not only the physical but also the emotional wellbeing of nurses. Physical effects can manifest as injuries and disabilities, while emotional harm includes stress and depression. Importantly, as Arnetz, Hamblin, Essenmacher, Upfal, Ager, and Luborsky (2014, p. 340) point out, patient-related violence need not be physical. The most common form of violent and aggressive behavior towards nurses is verbal abuse, which most often takes the form of swearing (McNamara, 2010, p. 676). When such violence persists over time without being addressed, significant psychological trauma can set in. In some instances, emotional harm can be extensive and long-lasting, causing irreversible damage to the affected nurse's wellbeing in the form of nightmares, palpitations, and related symptoms.
Violence from patients towards nurses can also impair a nurse's ability to perform their duties effectively, leading to suboptimal performance — particularly as a result of emotional trauma. This may manifest as absent-mindedness or diminished concentration. When the effects of patient violence are severely traumatic, the nurse may need to take days or even weeks off work (McNamara, 2010, p. 674), leaving care settings without adequate staffing. The far-reaching impacts on nursing practice are therefore considerable.
It should also be noted that exposure to violent situations can result in changes in a nurse's attitude towards those they are responsible for caring for, and can lead to a loss of faith in the profession. As Cowen and Moorhead (2014, p. 190) observe, nurses have in the past changed professions entirely as a consequence of constant exposure to workplace violence. This talent loss robs the profession of skilled individuals whose contributions could have benefited both patients and the broader nursing community.
On the basis of the impact that patient violence has on nurses and the profession, healthcare institutions must embrace effective strategies to protect nurses. These strategies are explored in the sections below.
According to the World Health Organization (WHO, 2018), patient safety concerns "the prevention of errors and adverse effects to patients associated with health care." Generally, when nurses are subjected to violence from patients, this can affect their relations with the concerned patients. Strained relations may take the form of reduced affection and diminished empathy. This is consistent with basic human nature — it is difficult not to feel offended when treated unfairly, particularly when the perpetrators are beneficiaries of the affected party's care. In some instances, diminished empathy may extend to other patients in the facility. As a result, the quality of care delivered can suffer in two ways. First, when a nurse is distracted by an actual threat or fear of violence stemming from a previous incident, their level of concentration can be compromised, triggering erratic decisions during the delivery of nursing care. Second, reduced empathy may lead nurses to neglect their duties to a patient, producing adverse effects. Examples of such neglect include, but are not limited to, late administration of medications, dosage errors, and failure to fulfill key responsibilities such as ensuring adequate ventilation and lighting.
Violent patients can also harm themselves in the course of an altercation, as Thomas, McIntosh, and Mensik (2015, p. 117) note. This is particularly concerning when patients have IVs, which can be dislodged during a sudden movement triggered by an episode of agitation. Similarly, falls resulting from a physical confrontation can adversely affect patient outcomes. As noted above, adverse effects and outcomes for patients are identified by the World Health Organization as central components of patient safety, alongside medical errors.
Instances of retaliatory behavior on the part of nurses cannot be ruled out either. There have been documented cases of nurses deliberately harming patients toward whom they harbor deep resentment — resentment that may have originated from violence inflicted upon the nurse by that patient. While seasoned nurses may have developed strategies for managing such situations, less experienced nurses, including new graduates, may lack the coping mechanisms to respond appropriately.
It is also important to note that a negatively affected care environment has direct consequences for patient safety. According to McNamara (2010, p. 679), "increased absenteeism, job dissatisfaction, and increased turnover further affect the environment of care," disrupting the care delivery system and increasing the likelihood of accidents, injuries, and errors. McNamara (2010, p. 681) further notes that "the consequences of workplace violence have been shown to increase the potential for medical errors or adverse effects."
"How nurse violence leads to care errors and neglect"
"Training, rapid response teams, and federal policy solutions"
"Cited academic and professional sources"
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