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November 19, 2014

Editor's Note: It was only earlier this month that another attack on nurses was reported, this time at a hospital in

Minnesota, when it appears that a patient suddenly became violent and attack ed nurses with a metal bar tak en from

his hospital bed. The frightening video shows how the nurses were attack ed as they sat in the nurses' station in the

middle of the night.

Brutal Attacks on Nurses

A nurse approached a patient's bedside to remove an intravenous (IV) catheter in preparation for discharge from the

hospital.[1] He lunged at her, hitting her with an IV pole and knocking her to the ground, stomping on her head, and

beating her repeatedly until she became unconscious. The nurse suffered head trauma and multiple fractures to her

face. She survived the attack but required neurosurgery and was in critical condition for some time. The patient, who

was not known to be dangerous, apparently became angry when told he was being discharged from the hospital.

Fortunately, such extreme incidents of violence are not everyday occurrences in healthcare. Still, they do happen, as

illustrated by the following headline-making incidents:

• At a psychiatric hospital in Maine, a patient attacked a nurse with a chair, injuring her face and head. In an earlier

incident in the same unit, another angry patient beat a nurse in the head and stabbed her with a pen.[2]

• A corrections facility nurse in Michigan was checking on an inmate whom she thought was having a seizure, when

he jumped up and attacked her.[3]

• At an ambulatory surgery center in Texas, a patient's son accused staff of trying to kill his mother, and he fatally

stabbed a nurse who tried to protect other patients from harm.[4]

• At a rehabilitation facility in Oklahoma, a man became angry when nurses removed his father's urinary catheter,

attacking a nurse with a wrench, pulling out some of her hair, and forcing her into a medication room.[5]

• In California, two incidents took place on the same day in different nearby hospitals. A visitor bypassed a weapons

screening station and purportedly stabbed a nurse 22 times. In the second incident, a visitor grabbed a nurse and

stabbed her in the ear with a pencil.[6]

These events show that attacks on nurses can be sudden, serious, and life-threatening. They take place in a broad

range of settings and involve patients, family members, and visitors who become angry for seemingly minor reasons

or for no apparent reason at all. Violence against nurses is more frequent in, but not limited to, the emergency

department (ED) or psychiatric units. It can happen in any healthcare setting, at any time. The unpredictable nature

of workplace violence in healthcare is what makes it so difficult to prevent.

And the violence is not just physical. Emotional, sexual, and verbal abuse are not only more common, but are much

more likely to be unreported. Nurses who are threatened with physical violence, but unharmed, do not always report

the incident to their supervisors. Thus, firm figures on the frequency of workplace violence in healthcare are elusive.

Reading about these incidents of violence is a little scary. After all, no nurse goes to work expecting to be physically

assaulted. Fortunately, the problem of workplace violence has not gone unnoticed by healthcare researchers, and

new data are expanding our understanding of the threat to nurses.

Step Away From That Nurse! Violence in Healthcare Continues Unabated Laura A. Stokowski, RN, MS

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A disheartening trend evident in the healthcare literature is that violence against nurses appears to be a growing

problem globally.In the past 2 years alone, articles have been published in the professional literature on violence

against nurses in the United Kingdom,[7] Ireland,[8] Australia,[9] New Zealand,[10] Switzerland,[11] Sweden,[12]

Slovenia,[13] Greece,[14] Turkey,[15] Cyprus,[16] Pakistan,[17] Iran,[18] Jordan,[19] Egypt,[20] Nigeria,[21] sub-Saharan

Africa,[22] Japan,[23] and China.[24]

Harassment to Homicide

If you have been a victim of workplace violence, you know what it is and what it feels like. Workplace violence is any

physical assault, threatening behavior, or verbal abuse directed at those who are at work or on duty.[25] Violence

includes overt and covert behaviors ranging in aggressiveness from verbal harassment to homicide.

Workplace violence can have both physical and psychological effects on the victim.Although the workplace violence

"umbrella" also includes worker-to-worker (lateral or horizontal) violence, this article focuses on violence perpetrated

by patients, family members, visitors, or other strangers in the healthcare setting.

When Dan Hartley, EdD, workplace violence prevention coordinator at the National Institute for Occupational Safety

and Health (NIOSH), is speaking to nursing groups, he wants to find out how many nurses in the audience have

experienced workplace violence. "I've learned to say, 'Raise your hand if you have never experienced workplace

violence,'" says Hartley. "It's much easier to count the hands because so few of them go up."

What Do the Numbers Say?

Although no one disputes the fact that violence occurs in healthcare, we are still hampered by a dearth of firm

statistics about the prevalence of workplace violence in healthcare settings. Data are collected from the Bureau of

Labor Statistics (BLS) only on episodes of nonfatal violence that result in days lost from work—in other words,

episodes that are reported and cause sufficient injury for the nurse to take time off from work.

However, surveys of nurses about their experiences with workplace violence suggest that, as a rule, only the most

serious incidents are reported. Many nurses neglect to report workplace violence if they haven't been physically

harmed, if they "excuse" the perpetrator's behavior for some reason, or if they believe that it is unlikely to be repeated

(because the patient or visitor is gone from the facility, for example, or the nurse is not scheduled to work the

following day).

Bearing in mind that they severely underestimate the prevalence of workplace violence involving nurses, the few

available statistics can do no more than hint at the scope of the problem, but they do suggest that violence is

increasing rather than decreasing.

BLS keeps statistics on the number of nonfatal workplace injuries that required days off from work. In 2012, a total of

19,360 episodes of violence or other injuries inflicted by persons or animals were reported in healthcare and social

assistance, almost equally divided between acts that were intentional and those that were considered unintentional or

intent unknown.[26] This equates to a rate of 15.1 incidents per 10,000 full-time workers,[27] and it represented a 6%

increase in violence against healthcare and social assistance workers.[28] When broken down by healthcare setting,

5910 incidents occurred in hospitals (15.6 per 10,000), 8990 in nursing or residential care facilities (37.1 per 10,000),

and 1790 (3.7 per 10,000) in ambulatory care centers and offices.[27] Considering reports by provider type, in 2012, a

total of 2160 episodes of workplace violence against registered nurses and 780 against licensed practical/vocational

nurses were reported.[29]

Most likely, these data underrepresent true rates of nonfatal workplace violence. We know from survey data of nurses

that workplace violence is common. A recent survey of 764 primarily white, female nurses employed by a large,

multihospital urban/community hospital system asked nurses how often they experienced episodes of physical or

verbal violence, and what they believed to be the causes of these incidents.[30] The survey response rate was 15.2%.

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During the past year, 76% experienced violence (verbal abuse by patients, 54.2%; physical abuse by patients,

29.9%; verbal abuse by visitors, 32.9%; and physical abuse by visitors, 3.5%), such as shouting or yelling, swearing

or cursing, grabbing, scratching, or kicking. Emergency nurses (12.1%) experienced a significantly greater number of

incidents (P < .001). The perpetrators were primarily white male patients, aged 26-35 years, who were confused or

influenced by alcohol or drugs.

Do Nurses Report Workplace Violence?

Nurses were also asked whether they reported these incidents of violence; reasons cited for not reporting included

not sustaining physical injury (49.5%), inconvenience (26.1%), and the perception that violence comes with the job

(19.6%). Other prominent reasons included being unclear about reporting policies, not wanting to draw attention to

oneself, and fear of retaliation or reprisals. Other evidence confirms that many nurses take a fatalistic view of reporting

workplace violence. They believe that reporting it is a waste of time, and nothing will be done about it anyway.[13]

Hartley finds another reason that some nurses don't report workplace violence. "Some nurses don't understand what

constitutes workplace violence. A patient might strike out at a nurse while he or she is giving a med, but that

happens all the time. Or nurses say that they only report violent behavior if they have to go the ED." Hartley tells of a

nurse who worked in a nursing home who had an "aha moment" at a workplace violence seminar. "I never thought of

being hit, kicked, or spit on by patients as violence, until I realized one day that it was the same patients doing it over

and over again. We weren't reporting it, so no one pinpointed the problem and nothing was ever done."

Workplace violence can, and has, happened in any area of healthcare. Although it is most frequent in three areas—

the ED, mental health settings, and geriatric care—no healthcare setting is immune. Violence toward nurses has

happened in labor and delivery, pediatrics, and ambulatory care. It happens in patients' rooms, waiting rooms, and

even in patients' homes. Workplace violence affects all healthcare workers, but nurses are the most likely to be

assaulted on the job.[31]

Healthcare Settings: High-Risk Workplaces

Like the nurse who has gotten used to patients striking out at her, nurses are often heard to say that violent acts by

patients and visitors are "just part of the job." Has violence become so prevalent in healthcare that it must now be

accepted as "going with the territory?"

"We tell nurses that violence isn't part of your job," says Hartley, "but violence prevention should be. The risk factors

for violence are more common in healthcare settings."

NIOSH divides the risk factors for violence into three categories: clinical, environmental, and organizational.[32]

Clinical risk factors are those that relate to the patient, family member, visitor, or other individual, and include such

characteristics as being under the influence of drugs or alcohol, having a history of violence, or being in the criminal

justice system. Sometimes, a reaction to a healthcare provider who is perceived as being authoritarian or who used

excessive force in the course of care can prompt anger. Some medical and psychiatric diagnoses are risk factors for

violence, although most people with mental illness are not violent.

Environmental risk factors for violence are features of the layout, design, or amenities of the setting that might

provoke frustration or anger, such as confusing signage, a lack of parking, or prolonged waiting. The environment can

also elevate risk by providing such opportunities for undetected violence as unmonitored stairwells, insufficient

lighting, or furniture and other items that could thrown or used as weapons. A lack of security systems, alarms, or

"panic buttons" to call for help can restrict a staff member's ability to respond appropriately to a sudden threat.

Organizational risk factors include inadequate attention to the risk for violence in the workplace, a lack of staff training

to prevent and manage violence, inadequate security and preparedness, and inadequate staffing.

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Can Healthcare Violence Be Predicted?

It would be unrealistic to suggest that violence can ever be completely eradicated from the healthcare environment

however many zero-tolerance policies are implemented. When people are sick or injured, emotions run high. People

are stressed, anxious, and unhappy. A more productive approach is to identify the behavioral cues that might foretell

violent behavior, and the situations most likely to precipitate violence, in line with the philosophy that "forewarned is

forearmed."

Picking up on the behavioral cues for violence has obvious benefits for the individuals in the line of fire, and an

increased awareness about the catalysts for violence can help healthcare facilities bolster their security and response

mechanisms. Electronic health records and data entry have made this type of analysis possible, but the benefits will

be realized only if nurses and others are encouraged to make reports for every incident of workplace violence,

regardless of whether physical injury occurs or the perceived intent of the action.

A recent study[33] assessed the situational factors that seemed to most frequently precede violent behavior on the

part of patients toward nursing staff. Using data from a centralized reporting system, all incidents (n = 214) during a

single year (2011) at an urban hospital were analyzed. These incidents were reported by nurses (39.8%), security

staff (15.9%), and nurse assistants (14.4%). Incidents of violence were found to be linked to specific patient

characteristics and behaviors (cognitive impairment, pain or discomfort, demanding to leave), patient care (use of

needles, use of restraints, physical transfer of patients), or situational factors (transitions in care, intervening to

protect patients or staff, and redirecting patients).

Another study[34] supports the fact that psychiatric and geriatric settings are prone to violence against nurses. A

survey of 284 nurses working in locked psychiatric units demonstrated a rate of verbal aggression of 0.6 incident per

nurse per week, and 0.19 incident per nurse per week for physical aggression. Episodes of violence were significantly

more common on the evening shift (compared with the day shift), and having more patients with personality disorders

was associated with higher rates of verbal and physical aggression.

An observational study[35] in an acute care geriatric ward targeted the behavioral cues that might serve as warning

signs for episodes of violence among elderly patients. Pacing around the bed universally preceded episodes of violent

behavior, and all patients who became violent had previously demonstrated shoving behavior.

Just as important as the number and features of reported incidents, however, is how nurses feel at work. Do they feel

safe, or are they frequently concerned about personal safety? Do they experience perceived threats, even if these

don't materialize into violence? A study[36] in a pediatric ED found that 26% of nurses were concerned for their safety

at least weekly, and that the primary causes for their anxiety were patient or visitor agitation (with violence potential)

and weapons in the ED. Most nurses believed that having a greater presence of security personnel or local police

would increase their feelings of safety at work.

A new tool assesses perceptions of personal safety of nurses. Burchill[37] designed and pilot-tested a survey

instrument, the Personal Workplace Safety Instrument for Emergency Nurses (PWSI EN), which was found to have

high content validity for identifying the factors that make nurses feel safe or unsafe at work.

A Free Training Course in Workplace Violence

What prevents the risk for workplace violence from becoming a reality is often the steps taken by healthcare settings

and staff to prevent, prepare for, and respond to violence in the workplace. A key element of this preparation is

training in workplace violence geared toward nurses and other healthcare providers who are most likely to be victims

of such violence—education that would seem to be mandatory for nurses who work in high-risk settings. "But when

we spoke to nurses at healthcare conferences, many would tell us that they didn't have access to violence training in

their work settings," said Hartley.

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It was imperative to address this gap, and provide the tools and techniques that nurses need to prevent and manage

workplace violence. NIOSH collaborated with Vida Health Communications and other experts in healthcare violence

prevention to develop an online course called Workplace Violence Prevention for Nurses that awards free continuing

education credits (2.6 contact hours) upon completion of the course's 13 modules. Course content was derived from

experts in the field of workplace violence and from the Occupational Safety and Health Administration's guidelines for

the prevention of workplace violence in healthcare.[38]

The course content is applicable for any healthcare professional or student who desires an introduction to workplace

violence prevention strategies. For nurses who don't have time to complete the course in one sitting, the course

applies "resume where you left off" technology.

Strengths of the course are hearing from nurses who have experienced violence in the workplace, and video case

studies involving violence in healthcare. Video case study scenarios include a psychiatric patient in the ED, an angry

husband on the postpartum unit, a death threat in home healthcare, a cognitively impaired patient in a long-term care

facility, and a bed-bound patient making inappropriate sexual advances. The case studies and personal stories will

resonate with nurses who have found themselves in similar situations, and perhaps wondered whether they could

have been handled differently. The vignettes inform viewers about the appropriate steps to take during and after

incidents of violence.

Using the crisis continuum as a model to describe how an individual progresses from normal stress and anxiety to a

loss of control, the course delineates intervention strategies, including verbal and nonverbal responses that can be

used to try and defuse tension and prevent the situation from escalating to violence. Nurses will learn about the

dynamics of power and control, and how these influence behavior not only in the aggressor, but in the nurse as well.

Is There an End to Workplace Violence?

Social and healthcare trends suggest that violence could continue to plague healthcare settings in the foreseeable

future. Our hospitals have become places for the sickest of the sick, intensifying anxiety and tension on the part of

friends and family members. Violence from the street spills over into urgent care facilities and trauma centers, and no

one is turned away.

ED crowding has not eased, so wait times continue to frustrate people seeking care. The burgeoning elderly

population is bringing with it an ever-expanding number of patients with dementia, and in many regions, access to

mental health care is insufficient. Although violence is not part of the job, dealing with potentially violent people is still

very real in healthcare.

Legislative solutions to workplace violence are being considered or have already passed in many states. Some of

these laws mandate establishment of workplace violence prevention programs in healthcare facilities, and others

increase penalties for those convicted of assaults on healthcare providers. However, many laws still pertain only to

specific settings, such as the ED. For example, Texas recently made it a third-degree felony to assault an ED nurse,

but it is still only a misdemeanor to assault a nurse elsewhere in a Texas hospital.[39] Except in the ED, it is a felony

to assault a nurse in only a handful of states. Clearly, we have more work to do.

To find out the laws in your state, visit the Emergency Nurses Association (ENA). The ENA also has extensive

workplace violence resources for nurses.

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