Summary week 6

10 American Nurse Today Volume 13, Number 5 AmericanNurseToday.com

ROBERT, a 78-year-old patient, re-

quests help getting to the bath-

room. When the nurse, Ellen, en-

ters the room, Robert’s lying in

bed, but when she introduces her-

self, he lunges at her, shoves her to

the wall, punches her, and hits her

with a footstool. Ellen gets up from

the floor and leaves the patient’s

room. She tells her colleagues what

happened and asks for help to get

the patient to the bathroom. At the

end of the shift, Ellen has a

swollen calf and her shoulder

aches. One of her colleagues asks

if she’s submitted an incident re-

port. Ellen responds, “It’s all in a

day’s work. The patient has so

many medical problems and a his-

tory of alcoholism. He didn't in-

tend to hurt me. What difference

would it make if I filed a report?”

These kinds of nurse-patient in-

teractions occur in healthcare set-

tings across the United States, and

nurses all too frequently minimize

their seriousness. However, accord-

ing to the National Institute for Oc-

cupational Safety and Health, “…

the spectrum [of violence]…ranges

from offensive language to homi-

cide, and a reasonable working

definition of workplace violence is

Patient violence: It’s not all in a day’s work

Strategies for reducing patient violence and creating a safe workplace

By Lori Locke, MSN, RN, NE-BC; Gail Bromley, PhD, RN; Karen A. Federspiel, DNP, MS, RN-BC, GCNS-BC

AmericanNurseToday.com May 2018 American Nurse Today 11

as follows: violent acts, including

physical assaults and threats of as-

sault, directed toward persons at

work or on duty.” In other words,

patient violence falls along a con-

tinuum, from verbal (harassing,

threatening, yelling, bullying, and

hostile sarcastic comments) to

physical (slapping, punching, bit-

ing, throwing objects). As nurses,

we must change our thinking: It’s

not all in a day’s work.

This article focuses on physical

violence and offers strategies you

can implement to minimize the

risk of being victimized.

Consequences of patient violence In many cases, patients’ physical vi-

olence is life-changing to the nurses

assaulted and those who witness it.

(See Alarming statistics.) As a re-

sult, some nurses leave the profes-

sion rather than be victimized—a

major problem in this era of nurs-

ing shortages.

Too frequently, nurses consider

physical violence a symptom of the

patient’s illness—even if they sus-

tain injuries—so they don’t submit

incident reports, and their injuries

aren’t treated. Ultimately, physical

and psychological insults result in

distraction, which contributes to a

higher incidence of medication er-

rors and negative patient outcomes.

Other damaging consequences in-

clude moral distress, burnout, and

job dissatisfaction, which can lead

to increased turnover. However,

when organizations encourage

nurses to report violence and pro-

vide education about de-escalation

and prevention, they’re able to alle-

viate stress.

Workplace violence prevention Therapeutic communication and as-

sessment of a patient’s increased

agitation are among the early clini-

cal interventions you can use to

prevent workplace violence. Use

what you were taught in nursing

school to recognize behavioral

The statistics around patient violence against nurses are alarming.

67% of all nonfatal workplace violence injuries occur in healthcare, but health- care represents only 11.5% of the U.S. workforce.

Emergency department (ED) and psychiatric nurses are at highest risk for patient violence.

Hitting, kicking, beating, and shoving incidents are most reported.

25% of psychiatric nurses experience disabling injuries from patient assaults.

At one regional medical center, 70% of 125 ED nurses were physically assaulted in 2014.

Sources: Emergency Nurses Association (ENA) Emergency department violence surveillance study 2011; ENA Workplace violence toolkit 2010; Gates 2011; Li 2012.

Alarming statistics

Effective communication is the first line of defense against patient violence. These

tips can help:

• To build trust, establish rapport and set the tone as you respond to patients. • Meet patients’ expectations by listening, validating their feelings, and respond-

ing to their needs in a timely manner.

• Show your patients respect by introducing yourself by name and addressing them formally (Mr., Ms., Mrs.) unless they state another preference.

• Explain care before you provide it, and ask patients if they have questions. • Be attentive to your body language, gestures, facial expressions, and tone of

voice. Patients’ behavior may escalate if they perceive a loss of control, and

they may not hear what you say.

• Control your emotions and maintain neutral, nonthreatening body language. • Strive for communication that gives the patient control, when possible. Example:

“Which of your home morning routines would you like to follow while you’re in

the hospital? Would you like to wash your hands and face first, eat your break-

fast, and then brush your teeth?”

• Offer a positive choice before offering less desirable ones. Example: “Would you prefer to talk with a nurse about why you’re upset, or do you feel as

though you will be so angry that you need to have time away from others?”

• Only state consequences if you plan to follow through. • Listen to what patients say or ask, and then validate their requests. • Discuss patients’ major concerns and how they can be addressed to their sat-

isfaction.

Despite these strategies, patients may still become upset. If that occurs, try these

strategies to de-escalate the situation before it turns violent.

• Nonverbal communication. “I see from your facial expression that you may have something you want to say to me. It’s okay to speak directly to me.”

• Challenging verbal exchange. “My goal is to be helpful to you. If you have questions or see things differently, I’m willing to talk to you more so that we

can understand each other better, even if we can’t agree with one another.”

• Perceptions of an incident or situation. “We haven’t discussed all aspects of this situation. Would you like to talk about your perceptions?”

Communication strategies

12 American Nurse Today Volume 13, Number 5 AmericanNurseToday.com

changes, such as anxiety, confu-

sion, agitation, and escalation of

verbal and nonverbal signs. Individ-

ually or together, these behaviors

require thoughtful responses. Your

calm, supportive, and responsive

communication can de-escalate pa-

tients who are known to be poten-

tially violent or those who are an-

noyed, angry, belligerent, demeaning,

or are beginning to threaten staff.

(See Communication strategies.)

Other strategies to prevent work-

place violence include applying

trauma-informed care, assessing for

environmental risks, and recognizing

patient triggers.

Trauma-informed care Trauma-informed care considers the

effects of past traumas patients ex-

perienced and encourages strategies

that promote healing.

The Substance Abuse and Mental

Health Services Administration says

that a trauma-informed organization:

• realizes patient trauma experi-

ences are widespread

• recognizes trauma signs and

symptoms

• responds by integrating knowl-

edge and clinical competencies

about patients’ trauma

• resists retraumatization by being

sensitive to interventions that

may exacerbate staff-patient in-

teractions.

This approach comprises six

principles: safety; trustworthiness

and transparency; peer support;

collaboration and mutuality; em-

powerment, voice, and choice;

and cultural, historical, and gender

issues. Applying these principles

will enhance your competencies

so that you can verbally intervene

to avoid conflict and minimize pa-

tient retraumatization. For more

about trauma-informed care, visit

samhsa.gov/nctic/trauma-interventions.

Environmental risks To ensure a safe environment, iden-

tify objects in patient rooms and

nursing units that might be used to

injure someone. Chairs, footstools,

I.V. poles, housekeeping supplies,

and glass from lights or mirrors can

all be used by patients to hurt them-

selves or others. Remove these ob-

jects from all areas where violent

patients may have access to them.

Patient triggers Awareness of patient triggers will

help you anticipate how best to in-

teract and de-escalate. (See Patient

triggers.) Share detailed information

about specific patient triggers dur-

ing handoffs, in interdisciplinary

planning meetings, and with col-

leagues in safety huddles.

What should you do? You owe it to yourself and your fel-

low nurses to take these steps to

ensure that your physical and psy-

chological needs and concerns are

addressed:

• Know the definition of work-

place violence.

• Take care of yourself if you’re

assaulted by a patient or witness

violence.

• Discuss and debrief the incident

with your nurse manager, clinical

supervisor, and colleagues.

• Use the healthcare setting’s inci-

dent reporting to report and doc-

ument violent incidents and in-

juries.

• File charges based on your

state’s laws.

Your organization should pro-

vide adequate support to ensure

that when a nurse returns to work

after a violent incident, he or she

is able to care for patients. After

any violent episode, staff and nurse

leaders should participate in a thor-

ough discussion of the incident to

understand the dynamics and root

cause and to be better prepared

to minimize future risks. Effective

communication about violent pa-

tient incidents includes handoffs

that identify known risks with spe-

cific patients and a care plan that

includes identified triggers and clin-

ical interventions.

Influence organizational safety You and your nurse colleagues are

well positioned to influence your

organization’s culture and advocate

for a safe environment for staff and

patients. Share these best practices

with your organization to build a

comprehensive safety infrastructure.

• Establish incident-reporting sys-

tems to capture all violent inci-

dents.

• Create interprofessional work-

place violence steering commit-

tees.

• Develop organizational policies

and procedures related to safety

and workplace violence, as well

as human resources support.

• Provide workplace violence-pre-

vention and safety education us-

ing evidence-based curriculum.

• Design administrative, director,

and manager guidelines and re-

sponsibilities regarding commu-

nication and staff support for

victims of patient violence and

those who witness it.

• Use rapid response teams (in-

cluding police, security, and pro-

Recognizing and understanding pa-

tient triggers may help you de-esca-

late volatile interactions and prevent

physical violence.

Common triggers

• Expectations aren’t met

• Perceived loss of independence

or control

• Upsetting diagnosis, prognosis,

or disposition

• History of abuse that causes an

event or interaction to retrauma-

tize a patient

Predisposing factors

• Alcohol and substance withdrawal

• Psychiatric diagnoses

• Trauma

• Stressors (financial, relational, sit-

uational)

• History of verbal or physical vio-

lence

Patient triggers

tective services) to respond to violent behaviors.

• Delineate violence risk indicators to proactively identify patients with these behaviors.

• Create scorecards to benchmark quality indicators and outcomes.

• Post accessible resources on the organization’s intranet.

• Share human resources contacts.

Advocate for the workplace you deserve Physically violent patients create a workplace that’s not conducive to compassionate care, creating chaos and distractions. Nurses must advocate for a culture of safety by encouraging their organ- ization to establish violence-pre- vention policies and to provide support when an incident occurs.

You can access violence-preven- tion resources through the Ameri- can Nurses Association, Emergency Nurses Association, Centers for Dis- ease Control and Prevention, and the National Institute for Occupa- tional Safety and Health. Most of these organizations have interactive online workplace violence-preven- tion modules. (See Resources.) When you advocate for safe work envi- ronments, you protect yourself and can provide the care your patients deserve.

The authors work at University Hospitals of Cleve-

land in Ohio. Lori Locke is the director of psychiatry

service line and nursing practice. Gail Bromley is the

co director of nursing research and educator. Karen A.

Federspiel is a clinical nurse specialist III.

Selected references Cafaro T, Jolley C, LaValla A, Schroeder R.

Workplace violence workgroup report. 2012.

apna.org/i4a/pages/index.cfm?pageID=4912

Emergency Nurses Association. ENA toolkit:

Workplace violence. 2010. goo.gl/oJuYsb

Emergency Nurses Association, Institute for

Emergency Nursing Research. Emergency

Department Violence Surveillance Study.

2011. bit.ly/2GvbJRc

Gates DM, Gillespie GL, Succop P. Violence

against nurses and its impact on stress and

productivity. Nurs Econ. 2011;29(2):59-66.

National Institute for Occupational Safety

and Health. Violence in the workplace:

Current intelligence bulletin 57. Updated

2014. cdc.gov/niosh/docs/96-100/introduc

tion.html

Occupational Safety and Health Administra-

tion. Guidelines for Preventing Workplace

Violence for Healthcare and Social Service

Workers. 2016. osha.gov/Publications/osha

3148.pdf

Speroni KG, Fitch T, Dawson E, Dugan L,

Atherton M. Incidence and cost of nurse

workplace violence perpetrated by hospital

patients or patient visitors. J Emerg Nurs.

2014;40(3):218-28.

Substance Abuse and Mental Health Servic-

es Administration. Trauma-informed ap-

proach and trauma-specific interventions.

Updated 2015. samhsa.gov/nctic/trauma-

interventions

Wolf LA, Delao AM, Perhats C. Nothing

changes, nobody cares: Understanding the

experience of emergency nurses physically

or verbally assaulted while providing care. J

Emerg Nurs. 2014;40(4):305-10.

• American Nurses Association (ANA) (goo.gl/NksbPW): Learn more about

different levels of violence and laws and regulations, and access the ANA posi-

tion statement on incivility, bullying, and workplace violence.

• Centers for Disease Control and Prevention (cdc.gov/niosh/topics/vio-

lence/training_nurses.html): This online course (“Workplace violence preven-

tion for nurses”) is designed to help nurses better understand workplace vio-

lence and how to prevent it.

• Emergency Nurses Association (ENA) toolkit (goo.gl/oJuYsb): This toolkit

offers a five-step plan for creating a violence-prevention program.

• The Joint Commission Sentinel Event Alert: Physical and verbal violence

against health care workers (bit.ly/2vrBnFw): The alert, released April 17,

2018, provides an overview of the issue along with suggested strategies.

Resources Screen & Intervene:

Addressing Food

Insecurity Among

Older Adults

FREE Online Course

Check out the course today at

senior health and hunger.org

Hunger is a

health issue.

People experiencing food

insecurity are more likely to

suffer from chronic

conditions such as

diabetes, heart disease and

depression. In just 60

minutes, health care

providers and community-

based partners can learn

how to screen patients age

50 and older for food

insecurity and connect

them to key nutrition

resources.

This Enduring Material activity, Screen and

Intervene: Addressing Food Insecurity

Among Older Adults, has been reviewed

and is acceptable for up to 1.00 Elective

credit(s) by the American Academy of

Family Physicians. AAFP certification

begins 10/28/2017. Term of approval is

for one year from this date. Physicians

should claim only the credit commensurate

with the extent of their participation in the

activity.

AmericanNurseToday.com May 2018 American Nurse Today 13

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