Violence: Not in My Job Description

Laura A. Stokowski, RN, MS

Disclosures

August 23, 2010

In This Article

Workplace Violence in Healthcare Settings

Have you ever been slapped, kicked, shoved, or bitten by a patient? Have you had your hair, earring, or clothing pulled? Has a patient ever thrown something at you, knocked something out of your hands, or spit in your face? Has a relative used abusive language, sworn at you, or threatened you if you tried to enforce a hospital policy or did not comply with a demand?

If the answer to all of these questions is "no," consider yourself one of the lucky few nurses to have escaped verbal and physical abuse at the hands of patients, family members, or visitors in the course of your duties.

The National Institute for Occupational Safety and Health Administration (NIOSH) and the Occupational Safety and Health Administration (OSHA) define workplace violence as "any physical assault, threatening behavior or verbal abuse occurring in the workplace."[1] This article addresses workplace violence initiated by patients, visitors, or any other persons not affiliated with the workplace, not violence inflicted by one healthcare professional on another. "Lateral" or "horizontal" violence, which includes bullying and other forms of nurse-to-nurse aggression,[2] is also a form of workplace violence and will be addressed in a future article.

The hospital has traditionally been viewed as a safe haven, a place where anyone can go and, at least temporarily, be protected and cared for.[3]Increasingly, the culture of violence in society has invaded the hospital, and the hospital has lost its status as a refuge.[4] Moreover, whereas violence was once primarily limited to the emergency and psychiatric units, it has inched its way into the rest of the facility. No one is immune.[5]

All in a Day's Work?

Of all the expectations that nurses have of their employers, feeling safe at work should be at the top of the list. If nurses don't feel safe, and if they believe that their employer tolerates violence, loss of trust will follow. Nurses will be reluctant to report abuse because they are pessimistic about administration's response – managers won't care, they will blame the nurse, or they simply won't do anything about it. "The first time I was assaulted by a patient," explains Rebekah Howerton Child, RN, MSN, CEN, "I was spit in the face. When I tried to report it to the police, they said, 'You're a healthcare worker – you are expected to be assaulted. Get used to it, there's nothing we can do about it.' So, tomorrow, if I get hit in the face, what is the likelihood that I will report it?"

Child is an emergency department (ED) nurse and doctoral student who is studying violence against nurses and its many ramifications. Little is being done about violence in many settings, a problem that is exacerbated by a lack of data, which in turn is caused by failure to report violent incidents when they occur.

Reporting Violence at Work

Nurses may fear that reporting violence will affect patient satisfaction scores, or that the hospital administration will retaliate.[6] Some don't know the hospital's reporting policy or believe they can only report visible physical injuries. Other nurses avoid reporting violence because they believe that supervisors will question their competence, suspect that they somehow provoked the incident, or label them as troublemakers if they have no obvious physical injury.[7,8] When nurses do report incidents of abuse, more than 85% do so only verbally.[9]

For all these reasons, violence in healthcare settings may be grossly underestimated. As much as 70% of abuse toward nurses may be unreported.[10] Most nurses who are injured do not seek treatment for their injuries, another indicator of a degree of resignation on the part of victimized nurses. The prevailing attitude that being abused by patients and visitors goes with the territory is an impediment to ending violence against nurses.

Sadly, some nurses who hesitate to report abuse might have a point. When incidents of violence are reported or reviewed, the nurse is often asked such questions as, "What did you do to cause this to happen?" or "What would you do next time so this would not happen?"[11] Incident reports (event reports) often ask this question. The clear implication is not only that the abuse is the fault of the victimized nurse, but also that he or she could easily have prevented it. Unbelievably, nurses are often reprimanded or fired if they defend themselves against violence.[12] One psychiatric nurse, who was raped on the unit, was fired afterward.

Is this a situation where hospitals take "customer care" or "customer service" too far? Or is blaming the victim a way of avoiding responsibility for and solving the problem, whatever it takes -- more staff, more security, more training -- solutions that cost money?

Child, coauthor of the article "Violence Against Women: The Phenomenon of Violence Against Nurses,"[13] doesn't buy the excuse that assaults against nurses are just an occupational hazard. "If violence is part of the job, then why isn't it included in basic nursing curricula?" asks Child. "Why isn't violence prevention included in hospital orientation? Nurses and students are routinely prepared for everything else that is 'part of the job.'"

"If you want to get accurate data, you have to have nurses, from the ground up, saying, 'No, this isn't part of the job. I shouldn't come to work for 12 hours and expect to be assaulted.' But you also have to have managers and professional nursing organizations say, 'You need to report this and I will support you.' It has to come from both directions."

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