Violence: Not in My Job Description

Laura A. Stokowski, RN, MS


August 23, 2010

In This Article

Features of Workplace Violence Incidents

Studies have been conducted to answer such questions as "Where does most workplace violence take place?" "Who are the offenders?" and "What precipitates violence against nurses?"

Violence can occur anywhere in the hospital, but, according to OSHA, it is most frequent in[1]:

  • Psychiatric/behavioral units;

  • Emergency departments;

  • Waiting rooms; and

  • Geriatric units and long-term care facilities.

Recently, an increase in violent behavior has been observed in intensive care units, which include neonatal, pediatric, and adult critical care. A study of nurses across Canada also found high levels of physical abuse reported by nurses working in palliative care and emotional abuse in long-term care.[21]

Between 45% and 96% of violence committed against nurses in healthcare facilities is inflicted by patients.[12,17] Violent acts against nurses are also committed by family members of patients and other visitors. Survey data also reveal that most abusers are male; they are often cognitively impaired and older than 66 years (for physical violence) or between 35 and 60 years of age (for verbal violence).[22]Drug and alcohol use may also be a factor.

Nurses surveyed in a large Florida medical center found that violence was most commonly perpetrated by patients with cognitive dysfunction (79.1%), patients with substance abuse (60.5%), and family members who were angry about the patient's condition (55.8%). The most common reasons for assault by family members and visitors were anger related to enforcement of hospital policies (58.1%), anger related to the patient's condition or situation (57%), anger related to long wait times (47.7%), and anger related to the healthcare system in general (46.5%).[17]Physical and psychological abuse enacted by patients with dementia is not surprising, in light of research showing that these patients are not infrequently abusive toward their regular caregivers.[23]Opinions about the caregiving situation may contribute to the risk for violence against nurses, particularly when patients or families perceive that their needs are not being met.[13]

In 1969, Elisabeth Kübler-Ross's landmark description of the stages of grief was published.[24] It didn't take long for healthcare professionals to realize many people go through all or some of these stages, not just when they encounter death and dying, but whenever they are threatened or perceive that they are threatened with tragedy or loss on a smaller scale and feel helpless and powerless to alter the situation.

The second stage of grief, anger, is particularly apparent because it often involves lashing out at a third person -- someone who is not actually responsible but is convenient -- and that person is often a nurse. A person who perpetuates violence in these circumstances is seeking someone to blame (and punish) for their suffering. It might be because a loved one or a child is hurt or sick and the spouse or parent feels powerless to help them. It might be an injury caused by an accident, and with no one else at hand to blame, the nurse becomes an easy target. Fear, anxiety, and frustration are the usual drivers of anger and aggressive behavior, but these are explanations rather than excuses for such behavior, a point that nurses need to remember.


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