Human Resource Challenges

A re you plagued by violence in your workplace? Yes, according to the nearly 1,400 respondents to Nursing Management’s first survey of this kind. An overwhelming majority of you— 1,377—representing every region of the United States and 17 other countries from as far away as Afghanistan, Taiwan, and Saudi Arabia claim that employee safety in healthcare doesn’t

really exist. Alarmingly, nearly 80% of surveyed nurse leaders have experi- enced some form of violence within the work setting.

Unsettling findings: Employee safety isn’t the norm in our healthcare settings.

By Richard Hader, RN, CHE, CPHQ, NE,BC, PhD, FAAN

Nursing Management July 2008 13www.nursingmanagement.com

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Have nurses left our profession in fear of intimidation, harassment, or even physical harm? Will the health- care industry be able to recruit and retain skittish clinicians? Do budget cuts that cause short staffing prompt so many colleagues to have angry outbursts within the clinical setting? As nurse leaders, we and our admin-

istrative colleagues must address this issue with vigilance and swift action to protect nurses, our most valued resources.

What’s the problem? The University of Iowa Injury Pre- vention Research Center has de- fined four categories of workplace violence: criminal intent, customer/ client, worker-on-worker, and per- sonal relationship.1 Criminal intent is described as those activities in which a person who has no rela- tionship with the business commits a crime such as a felony or murder. When those for whom you provide a service, such as a patient or fam- ily member, display acts of vio- lence, it’s considered customer/client

Violence survey

Will the healthcare

industry be able to recruit and retain skittish

clinicians?

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workplace violence. Collegial vio- lence is violence between co- workers. Domestic violence often extends to the employment setting because abusers track down their victims at work.

Workplace violence within health- care isn’t new. The Bureau of Labor Statistics found that 48% of all non- fatal injuries from occupational assaults happened to nurses and their assistive personnel within a hospital setting. Approximately 22 of every 1,000 nurses have fallen victim to workplace violence.2 But even considering these alarming statistics, few healthcare organiza- tions have developed and imple- mented a comprehensive work- place safety program.

Who are you? The majority of respondents are female (92.8%), consistent with national statistics representing the percent of females licensed as regis- tered nurses. Over 83% are greater than age 36; 80% work within a hospital setting that operates be- tween 101 and 500 beds. Sixty per- cent of you have been employed in the profession greater than 20 years. Nurses in outpatient ser- vices, community health, and the academic setting each represented 5% of the total sample, along with long-term care (4%), rehabilitation care (2%), and sub-acute care (1%).

There were representatives from all levels of nursing leadership, with a majority of you holding the title of nurse manager (34.7%), fol- lowed by director (14.4%) and edu- cator (11.3%). Medical/surgical, critical care, ED, OR, maternal/ child health and psychiatric nurse leaders were all represented in the survey.

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Violence survey

Over 70% of you in our sample have been a nurse longer than 15 years, with an average tenure of 21.8 years. Nearly 80% of you have at least a bachelor’s degree.

Almost half of you categorized yourselves as working in urban areas, 28% in the suburbs, and 21% in rural areas.

The largest group of respondents (21.4%) work in the East North Central region of the United States, but participants hailed from all regions.

The frequency of workplace vio- lence is a sobering reality. More than 73% of you report that workplace violence is experienced occasionally, 19% frequently, and 1.7% always. Only 5.2% shared that you never wit- nessed violence at work.

The victim Patients and their family and friends, nurses, physicians, and other health-

care providers have all been victims of workplace vio- lence. Nearly 80% of you report witnessing a nursing colleague subjected to work- place violence. Fifty-six per- cent of you report having been “prey” yourselves, and 50% of you have seen other healthcare providers succumb to violence. Our research also found that 21% of our patients have been victimized and a surprising 15% of physicians have also been the recipients of violence.

Healthcare providers expect to come to work to care for people without fear of poten- tial or actual threats against them. Yet, the following nurse reports this often isn’t the case. “I was grabbed by the arm by a fellow employee who wanted me to listen to her rant. I was intimidated.

That RN threatened to bring in a gun and blow people away.”

And, of course our patients rely on us to treat them safely and with dignity and respect. Unfortunately, there are those of us who don’t. One respondent reported that a resident physi- cian assessing a coma- tose patient for pain response wrapped a cold wet towel and swung it at the pa- tient’s foot to see if there was a response to the stimuli.

The perpetrator Surprisingly, nurses are subject to violence most commonly from

patients (53.2%), followed by nurs- ing colleagues (51.9%), physicians (49%), visitors (47%), and other healthcare providers (47%). ED nurse leaders claim that patients are their greatest source of violence.

Wicked words Verbal rather than physical forms of violence appear to be more common in healthcare settings. Intimidation, extreme criticism, belligerence, threatening behavior, bullying, and harassment have been witnessed by more than half of our respondents. Threats or actual physical violence are reportedly somewhat common, whereas more violent crimes with weapons or intentional property damage is significantly less frequent.

Over 75% of you cited intimida- tion as the most frequent form of workplace violence. “I left a terrific career and job after almost 10 years because my boss intimidated me, slammed books when involved in discussions with me, and consis- tently yelled at me,” recalled one

Frequency of violence

73.7% occasionally

19.4% frequently

5.2% never 1.7% always

Types of violence

Intimidation 75.9% Angry outbursts 71.9% Hypersensitivity to criticism 71.5% Belligerence 66.9% Threatening/disruptive behavior 64.6% Bullying 59.8% Harassment 51.6% Threats of physical violence 38.9% Obsession with a supervisor 28.5% Ominous or specific threats 27.9% Physical violence 25.8% Intentional property damage 17% Preoccupation with recently

publicized violent events 8.3% Carrying or storing weapons 7.5% Preoccupation with violent themes 5.9% Recent acquisition of or fascination

with weapons 5.6%

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respondent. This form of vio- lence often isn’t reported. “The abuse occurred behind closed doors and there were no wit- nesses. But she [supervisor] presents a professional appear- ance and many staff sing her praises,” recalled one nurse who transferred to another unit to retreat from her attacker.

Outbursts of anger are the second most common form of violence realized by nurses. “I’ve worked in a community hospital where passive aggres- sive behavior was acceptable behavior.” The nurse further explains that she’s suffered out- bursts both from student nurses when she was working as a clinical instructor and from a colleague when she was a staff nurse.

Some nurses believe that the gene- sis of these outbursts are a direct reflection of a healthcare system that’s under funded and causes “patients, families, and staff, to become frustrated and angry when substandard care is pro- vided in order to meet the bottom line.”

A startling 71% of you re- sponded that you’re subject to severe criticism from supervi- sors, physicians, colleagues, and patients. Many of you shared that you’re victim to supervisors who wrongfully criticize you. “I consistently see persons in posi- tions of power exhibit these behaviors. This includes not only physicians but also nursing directors, managers, and super- visors—despite the dialogue about zero tolerance.” “I changed jobs after 29 years because of what I had to deal with in my previous place of employment,” recalled one respondent after working in a

threatening environment. She isn’t alone; greater than 70% of you re- ported witnessing disruptive verbal attacks and behavior in the work setting.

Although less common than ver- bal assaults, physical violence, obsession with supervisor, ominous

or specific threats, intentional prop- erty damage, preoccupation with recently publicized violent events or themes, carrying or storing of weapons, and a recent acquisition or fascination with weapons do occur in our healthcare settings. One respondent shared that she had

her “fingers smashed on a pro- cedure table by a doctor in the cath lab because I was new and didn’t know how to hold the wire during the procedure. I’ve been shoved and berated by physicians. If another physician touches me, I’m suing him and the hospital.”

Workers obsessed with their supervisors are more common than expected, with 28.5% of you reportedly witnessing this behavior. A psychiatric unit nurse manager recalls having two employees, many years apart, become clinically para- noid about her. She stated that in one instance the employee was made to go out on medical leave but in the second scenario administrators didn’t support her claims, so she’s chosen not to pursue resolution in fear of exacerbating the situation.

Perpetrator

Patient 53.2% Nursing colleague 51.9% Physician 49% Visitor 47% Other healthcare worker 37.7%

Victim

Nursing colleague 79.7% Respondent 56.1% Other healthcare provider 50.5% Patient 21.1% Physician 15.5% Visitor 10.9%

A startling 71% of you responded that you’re subject to severe criticism

from supervisors, physicians, colleagues, and patients. Many of you shared that you’re victim to

supervisors who wrongfully criticize you.

Meaningful measures? More than 40% of you claim that your organization doesn’t provide formal zero-tolerance policies and procedures to thwart off workplace violence. But those of you who have these policies don’t believe that they’re effective: “We do have a zero-tolerance policy in place, but nothing happens if violence occurs. We’re frequently as- saulted by our patients,” says one nurse manager. Others echoed that these policies are “just lip service” and aren’t enforced if they involve a phy- sician.

Leaders will refer employees to behavioral health specialists when they’re having difficulties in their professional or personal life. Almost 80% of employers do have em- ployee assistance programs avail- able to help staff members, and just shy of 40% report conflict manage- ment programs.

Being prepared for an actual or potential threat of violence is im- perative for all healthcare organiza- tions. Thirty-eight percent of re- sponding leaders have emergency response teams, 18.9% participate in

mock drills, 16% have alternative dispute resolution, and slightly over 5% have threat assessment teams.

Photo identification for employ- ees and security presence are com- mon in healthcare organizations. Access to buildings and grounds are prohibited unless permitted by the employee’s coded badge. Al- most a quarter of you report having sign-in procedures for visitors, but only 6% have metal detectors.

Forty-two percent of you have received education and training in workplace violence. Specifically, 20.3% were educated on conflict

prevention, 20.8% on workplace security, and 18.2% on a drug- free workplace.

Safer sources So, what’s a nurse leader to do, given this current climate? Establish a committee to con- duct organizational assessments regarding safety of team mem- bers, patients, and visitors. Leaders and employees should be actively involved in this assessment to ensure that all safety risks are appropriately discovered and a plan devel- oped and implemented to miti-

gate the chance of violence. If you haven’t already, immedi-

ately institute a zero-tolerance work- place violence policy supported and enforced by senior-level administra- tors and medical staff. A culture that respects the rights and dignity of all can only be accomplished if there are absolutely no exceptions to policy adherence.

Violence prevention educational programs must be mandated for all leaders, staff members, and physi- cians. Through appropriate education and intervention, de-escalation of incidents will have a greater chance of effectiveness resulting in a less likely chance of a violent outcome.

Remain constantly cognizant of the tenor of your team members’ mood and frustration tolerance. Predeter- mined stressors in the workplace must be addressed quickly to avoid escalation and likelihood of violence. Offering breaks, flexible time off, providing opportunities to express concerns in a nonthreatening envi- ronment, and recognition of good performance are all strategies you should employ to support your team.

Technology can—and does—sup- port a safer environment. Cameras monitored by security personnel

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Violence survey

Clinical setting of leader

Number of Area respondents

Medical/surgical 375 Critical care 219 ED 139 Maternal /child health 137 Psychiatry 129 OR 102

Immediately institute a zero-tolerance workplace violence policy supported

and enforced by senior-level administrators and medical staff.

should be deployed throughout your organization, par- ticularly in high-risk areas such as the ED and psychi- atric units. Stationary or portable panic alarms should be carried by staff if appropriate to the work setting. These alerts should transmit directly to security person- nel to enable quick assistance.

Workplace violence is of grave concern to all who work in healthcare. Every staff member, every leader must share the responsibility of ensuring a safe envi- ronment. Reporting and monitoring of incidents of vio- lence should be trended to determine the cause or to implement new strategies to improve safety. This prob- lem can be minimized through the promotion of a cul- ture which values the safety, respect, and dignity of all persons. Our findings are a call to action: Protect your patients and yourselves! NM

REFERENCES 1. Guidelines for Preventing Workplace Violence for Health Care

& Social Service Workers OSHA 3148-01R2004. 2. California Department of Industrial Relations. Cal/OSHA guide-

lines for workplace security. Available at: http://www.dir.ca. gov/dosh/dosh%5Fpublications/worksecurity.html. Accessed May 30, 2008.

ABOUT THE AUTHOR In addition to his role as editor-in-chief of Nursing Management, Richard Hader is senior vice-president and chief nurse officer at Meridian Health, Neptune, N.J.

ABOUT THIS SURVEY Nursing Management's Workplace Violence Survey 2008 was published in the November 2007 through March 2008 issues of the journal and online at http://www.nursingcenter.com/NM/ workplace/survey from November 1 through April 30. Franklin Communications, a research firm in Rockaway, N.J., tabulated data from 1,377 respondents.

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Implemented measures

Photo identification badges 82.9% Employee assistance programs 78.7% Security guard services 68.2% Zero-tolerance policies 59.5% Pre-employment screening 52.5% Key card access to buildings 48.7% Education/training 42% Controlled facility access 41.8% Conflict management programs 39.9% Emergency response team 38.1% Alternative dispute resolution 16% Threat assessment team 5.1%