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Running Head: PSYCHOLOGICAL EFFECTS OF WORKPLACE VIOLENCE AGAINST

REGISTERED NURSES

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Psychological Effects of Workplace Violence Against Registered Nurses

Samantha Stryczek

Widener University, School of Nursing

Psychological Effects of Workplace Violence Against Registered Nurses

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Abstract

Workplace violence (WPV) is a common clinical issue surrounding registered nurses (RNs) who

work in the emergency department (ED). Due to the nature of an RNs occupation, they are

constantly interacting with patients and their family members. These interactions are not always

pleasant. The type of violence that an RN is suspectable to is verbal and physical abuse, sexual

harassment, stalking, and even homicide. The study designs that were analyzed utilized a cross-

sectional survey, semi-structured interviews with RNs, and a literature review of WPV

interventions. Through this analysis, it was discovered that those with less experience and

females are more susceptible to developing anxiety and depression. Additionally, WPV in

general, had a significant role in developing these mental conditions. The limitations to the

studies involved small sample sizes and focused population. To fully comprehend the magnitude

of WPV on ED nurses, larger sample sizes and a broader population focus need be implemented.

Furthermore, violence prevention training and increased nursing management and hospital

administrator’s involvement are required.

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Introduction

Registered nurses (RN) who are employed in the emergency department (ED) are

subjected to numerous challenges. One of these obstacles consists of experiencing psychological

or physical harm from a patient. Workplace violence (WPV) can be expressed as an act of

aggression that is directed toward an individual at his or her place of employment. (Hassankhani

et al., 2018). These types of threats can range from assault, verbal abuse, harassment to homicide

which result in significant physical and mental anguish (Hassankhani et al., 2018). Those who

have experienced workplace violence are more suspectable to experiencing psychological

disorders such as anxiety and depression (Liu et al., 2019). Further support from hospital staff

and leadership is required to encourage ED nurses to complete incident reports along with

providing effective coping strategies.

Clinical Issue

The main concern for registered nurses employed in the ED is the rising number of WPV

events. According to the Occupational Safety and Health Administration (OSHA), episodes of

severe workplace violence are four times more likely to take place in the healthcare setting as

opposed to private industries (TJC, 2018). Even though most WPV incidents typically involve

verbal threats, other forms of abuse such as assault, battery, stalking, and sexual harassment are

still occurring (TJC, 2018). TJC discusses a 2014 study regarding hospital crime that found 75%

of aggravated assaults and 93% of all assaults were against healthcare professionals from

patients (as cited in Vellani, 2014).

Abuse experienced by RNs in the ED can present in multiple forms. One ED nurse

described her WPV experiences as being bitten, kicked, punched, shoved, scratched, spit on,

bullied, called names, and threats made to their life and the lives of their unborn child and family

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members (The Joint Commission, 2018). It is estimated that only 28% of ED nurses actually

report WPV which is partially due to RNs simply thinking violence against them is part of the

profession (The Joint Commission, 2018). Between WPV being considered the norm and the

lack of reporting, RNs are susceptible to multiple psychological conditions. Some of the

emotions and disorders involved with WPV are anger, frustration, hopelessness, hyper-vigilance,

post-traumatic stress disorder (PTSD), depression, anxiety, and even leaving the nursing

profession (Martinez, 2016).

An evidence-based practice framework will be used to investigate the impact of WPV on

RNs’ mental health and the likelihood of developing anxiety or depression. The PICO question

that was established is among emergency department (ED) nurses who experience workplace

violence (WPV), does receiving training on managing WPV and aggression decrease depression

and anxiety compared to those who did receive any training? This question will be addressed

throughout the remainder of this paper.

Sources and Search Process

The search strategy that was utilized is the Widener University Wolfgram Library’s A

through Z databases. CINAHL was the particular database applied to discover nursing-specific

academic journal articles. The initial search consisted of a combination of the main main

keywords: mental health, workplace violence and emergency department (see Appendix A).

This search yielded 22 articles that were from various sources, including academic journals and

magazines. In order to achieve the goal of obtaining peer-reviewed scholarly journal articles with

full text, there were limitations put in place. These limitations involved altering the publication

dates from 2014 to 2020, receiving full text, and academic journal articles. This resulted in four

articles with one of those articles being used throughout this study.

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The next search that was conducted utilized the same data base which displayed the

following phrase, “psychological effects of workplace violence on nurses.” This search yielded a

total of 7,991 articles. The same limitations were placed on this search which presented 5,562

articles. Four more articles related to WPV in the ED against RNs were discovered. Lastly, for

intervention purposes, a search was conducted stating, “workplace violence in the emergency

department training.” Eleven thousand academic journals, magazines, CEUs, dissertations, and

pamphlets appeared. Once the limitations were put into use, the search resulted in 3,000 articles.

This is where several qualitative studies were discovered regarding WPV training. All of the

sources found through the various searches that were discussed will be further implemented to

answer the PICOT question.

Appraisal of the Evidence

In 2017, a qualitative exploratory designed study was conducted in five hospitals located

in West and East Azerbaijan, Iran (Hassankhani et al., 2018). There was a total of sixteen ED

RNs who participated in the study. Inclusion criteria involved having at least one year who

worked as an RN in the ED, wanted to participate, and experienced WPV (Hassankhani et al.,

2018). The main objective was to investigate the negative consequences that WPV has on ED

RNs. Researchers utilized a face-to-face, in-depth, and semi-structured interview approach.

During the interviews, participants were asked a series of questions regarding their experience

with WPV and the effects on their life, such as the mental health consequences. MAXQDA 10

software was utilized to interrupt the researcher’s findings, including a six-step analysis

approach (Hassankhani et al., 2018).

The researcher’s design is appropriate since dependability, credibility, transferability, and

conformability were applied to ensure the study’s trustworthiness and accuracy (Hassankhani et

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al., 2018). Regarding the demographics of the participants, all sixteen subjects expressed

experiencing WPV in the ED, ages ranged from twenty-six to forty-four years old, and work

experience was anywhere from two to eighteen years (Hassankhani et al., 2018). Hassankhani et

al. (2018) indicated that the main category, “suffering nurses,” emerged as a result of WPV

experiences (see Appendix B). This category provided four main subcategories involving mental

health risks, physical health risks, threats of professional integrity, and threats to social integrity

(Hassankhani et al., 2018). The subcategory “mental health” indicated that RNs feel stressed,

anxious, and depressed after experiencing WPV (Hassankhani et al., 2018). More specifically,

most of the participants expressed developing depression after a WPV incident, which they are

now prescribed anti-depressants for coping (Hassankhani et al., 2018). Another significant

emotional distress that the researchers were able to correlate with WPV is the manifestation of

anxiety and stress. These mental disadvantages contribute to other categories that appeared, such

as loss of interest in work, weak nursing interactions, daily activity impairment, disrupted family

relationships, and threats to social integrity (Hassankhani et al., 2018). The findings from this

study are incredibly significant to the nursing profession since it is evident that there is a growing

silent pandemic occurring among RNs in the ED who undergo WPV. After evaluating the

evidence, the researchers provided specific recommendations to combat violence. Hassankhani et

al. (2018) suggested implementing a violence prevention program that administrations’

commitment and safe involvement, workplace analysis to find potential risks, risk prevention and

control, continuing safety and health training, and regular monitoring of the program. The author

also advised the application of psychological counseling and support to ensure RNs reduce the

adverse outcomes of WPV incidents (Hassankhani et al., 2018). One of the limitations identified

was that the researchers solely focused on RNs who are currently working in the ED. Appose to

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incorporating interviews with RNs who left the ED after encountering WPV to understand better

the severity of the issue (Hassankhani et al., 2018).

The second study utilized a cross-sectional survey that was given to 888 RNs from the

Heilongjiang Province in China. Criteria needed participate involved being an RN, more than

one year of working experience, and signed informed consent (Zhao et al., 2018). The study’s

purpose was to evaluate the prevalence of WPV and the impact on RNs’ mental health. A total of

eight tertiary hospitals were selected from the cities of Harbin, Qiqihar, Jiamusi, and Mudanjiang

(Zhao et al., 2018). Participants consisted of those from a sample framework, along with the

recruitment of their colleagues. Each subject completed a survey with questions designed to

uncover the incident of WPV experienced by RNs and the influence of WPV on the RNs mental

health (Zhao et al., 2018). Once the surveys were all collected, the authors used the mean scores

on nine items derived from the WPV Scale (Zhao et al., 2018). Two dimensions were utilized to

identify the RNs’ mental health, which were anxiety and depression. Anxiety was examined

through the 20-item Self-Rating Anxiety Scale (SAS) with items being distinguished by the 4-

point Likert scale. Whereas the depression dimension was assessed with the Self-rating

depression Scale (SDS), and a 4-point scale was also applied. The higher the score, the higher

the degree of anxiety or depression (Zhao et al., 2018). This study is valid since the researchers

obtained approval by the Ethics Committee of Harbin Medical University. After determining the

demographics, the researchers applied a multiple linear hierarchical regression analysis to

pinpoint the influence of WPV on anxiety and depression (Zhao et al., 2018). Zhao’s et al.,

(2018) findings indicated that WPV was a strong predictor of anxiety and depression (see

Appendix C). Other significant discoveries are that fewer years of practice increases the

likelihood of WPV, and female RNs are more susceptible to developing depression after a

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violent altercation (Zhao et al., 2018). This is important to nursing due to pinpointing exactly

how and who is affected by WPV in order to apply a personalized intervention. To combat the

negative results of WPV, Zhao et al. (2018) suggested that hospitals construct personal resilience

to help RNs cope with WPV through positive nurturing networks. This can be accomplished

through the use of RNs with numerous years of experience teaching new RNs to increase their

psychological resilience (Zhao et al., 2018). Nursing managers can also implement evidence-

based findings related to WPV and apply them to their everyday practice (Zhao et al., 2018).

Since female RNs are shown to be more suspectable to depression after a WPV incident, the

nurse manager should observe the situation of WPV and provide counseling services for the

female RNs (Zhao et al., 2018).

Lastly, a review of evidence-based interventions was performed by Martinez in 2016 to

identify methods to help RNs minimize the incidence of WPV. The online databases used were

CINAHL and PubMed, emphasizing systemic reviews and quantitative and qualitative studies.

Martinez (2016) picked eleven articles about assaults perpetrated by patients against RNs. The

John Hopkins Nursing Evidence-Based Practice Non-Research Evidence Appraisal Tool was

applied to examine the evidence within the articles. The quality of the reviews was determined

using a rating scale of A being high, B meaning appropriate, and C indicating major flaws

(Martinez, 2016). All eleven of the articles chosen for this study were scored as either an A or B.

In 2013, a Pennsylvania hospital implemented a code green response team (CGRT). This team

consisted of an RN, physician, security personnel, and charge nurse.

The main objective of the CGRT was to de-escalate potentially violent situations with the

least restrictive measures (Martinez, 2016). These approaches consisted of verbal de-escalating

skills, non-coercive use of medications to control violent or escalating situations (Martinez,

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2016). Data was collected for one year using the post-violence debriefing tool along with

incident report forms. The results implied that 85% of CGRT calls ended in the successful

resolution of the violent situation (Martinez, 2016). Another point that the author emphasized

was to increase RNs’ awareness of WPV. This can be achieved by applying training programs

that focus on preventing and effectively managing violent episodes (Martinez, 2016). WPV

training programs should involve recognizing aggressive cues and behaviors, creating

therapeutic rapport, increasing communication skills, the use of verbal de-escalation skills, and a

team approach to managing assaultive behaviors in the clinical setting (Martinez, 2016). This

particular review of the literature did have two limitations, which are the use of quantitative

studies that specifically focused on psychiatric and emergency nursing and the lack of

pinpointing on one particular abuse (Martinez, 2016). It is essential to apply these findings to the

nursing profession because to help nurses cope after WPV, hospitals and administrators need to

know the methods to intervene.

Furthermore, nursing administrators play a critical role in combating WPV in a clinical

setting. Nurse managers can assess the nursing staff and risk factors to apply the appropriate

interventions (Martinez, 2016). Nursing administrators also need to listen to the concerns that

RNs have regarding safety, suggestions to manage violence, and address the issues with

evidence-based information (Martinez, 2016).

Summary of Practice Changes

The clinical issue of this research was to obtain identify whether ED RNs who experience

WPV training can decrease the likelihood developing depression and anxiety. Training is an

essential element that should be implemented earlier in the RNs’ career. The increasing number

of inexperienced RNs and females undergoing WPV is staggering. Zhoa et al., (2018) indicate a

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positive nurturing network that builds personal resilience so that new RNs can establish

emotional awareness and maintain their mental health. Veteran RNs can teach newer RNs the

appropriate skills associated with gaining mental toughness (Zhoa et al., 2018). Additionally,

violence prevention programs need to be implemented earlier in the RN’s career. Violence

prevention programs consist of administration’s commitment and staff involvement, workplace

analysis to identify risks, risk prevention and control, continuing safety and health training, and

regular monitoring of the program (Hassankhani et al., 2017). Within this type of program, the

design and implementation of a comprehensive reporting system should be developed. This

would include facilitating factors such as the RN’s reaction to WPV (Hassankhani et al., 2017).

Even though RNs may have their own personal coping strategies, nursing managers can also

empower these inexperienced RNs with education, improving communication, and adaptive

skills (Hassanskani et al., 2017). It is critical that nursing managers pay close attention to the

RNs’ concerns about their safety and management of violence (Martinez, 2016). The

implementation of psychological counseling after experiencing WPV plays a valuable role in

significantly decreasing the development of WPV consequences (Hassankani et al., 2017). All of

the studies had limitations associated with small sample sizes and the type of participants focus.

Furthermore, follow up studies should be considered to fully understand the effects of WPV

training on an RN’s mental status.

Conclusion

In conclusion, WPV poses a significant threat to ED RNs’ mental status. More specifically,

experiencing WPV increases the chances of an RN developing anxiety and depression. The RNs

who are being affected the greatest are those who lack experiences and are of the female gender.

A great deal of change needs to be implemented when it comes to combating ED violence against

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RNs. Altercations in violence prevention training and debriefing can establish de-escalation and

adaptive skills. It is also important to note that nursing managers and hospital administrators can

play an essential role in empowering new RNs and intervening with appropriate measures. Due to

the severity and vast number of ED and other nurses undergoing WPV, it is essential to determine

effective methods. Not only are the RNs’ professions at stake, but their personal lives are also

being hindered. RNs who experience WPV are letting the consequences affect their life outside of

the profession such as relationships and daily living activities. These consequences affect the RNs’

overall well-being, but families and partners are also suffering. More importantly, the care that

patients are receiving from these RNs is not of the utmost quality care. If RNs are unable to care

for themselves, how can they care for others?

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References

Hassankhani, H., Parizad, N., Gacki-Smith, J., Rahmani, A., & Mohammadi, E. (2018). The

consequences of violence against nurses working in the emergency department: A

qualitative study. International Emergency Nursing, 39, 20–25.

https://doi.org/10.1016/j.ienj.2017.07.007

Liu, J., Zheng, J., Liu, K., Liu, X., Wu, Y., Wang, J., & You, L. (2019). Workplace violence

against nurses, job satisfaction, burnout, and patient safety in Chinese hospitals. Nursing

Outlook, 67(5), 558–566. https://doi.org/10.1016/j.outlook.2019.04.006

Martinez, A. J. S. (2016). Managing workplace Violence with Evidence-Based Interventions.

Journal of Psychosocial Nursing & Mental Health Services, 54(9), 31–36.

https://doi.org/10.3928/02793695-20160817-05

The Joint Commission (2018). Physical and verbal violence against health care workers. Sentinel

Event Alert, (59). Retrieved from www.jointcommission.org

Zhao, S., Xie, F., Wang, J., Shi, Y., Zhang, S., Han, X., Sun, Z., Shi, L., Li, Z., Mu, H., Liu, X.,

Liu, W., Gao, L., Sun, T., & Fan, L. (2018). Prevalence of Workplace Violence Against

Chinese Nurses and Its Association with Mental Health: A Cross-sectional Survey.

Archives of Psychiatric Nursing, 32(2), 242–247.

https://doi.org/10.1016/j.apnu.2017.11.009

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Appendix A

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Appendix B

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Appendix C