Violence Against Nurses and its Impact on Stress and Productivity

Donna M. Gates, EdD, RN, FAAN; Gordon L. Gillespie, PhD, RN, FAEN; Paul Succop, PhD


Nurs Econ. 2011;29(2):59-67. 

In This Article

Abstract and Introduction


Workplace violence is a major public health concern that has received growing national attention. Recent media attention to school and workplace shootings raised the level of civic consciousness regarding the adverse effects of violence. Most Americans know the phrase "going postal" indicates an employee who becomes hostile at work. According to a report by the U.S. Bureau of Justice Statistics, an estimated 1.7 million workers are injured each year due to assaults at work (Duhart, 2001). However, much of the public's focus on violence is on occupational environments that are exclusive of health care sites. And while the homicide rate against health care workers is lower than other establishments, the assault rate remains the highest (Bureau of Labor Statistics [BLS], 2007). In 2006, the BLS reported 60% of workplace assaults occurred in health care, and most of the assaults were committed by patients (BLS, 2007). Health care support occupations had an injury rate of 20.4 per 10,000 workers due to assaults, and health care practitioners had a rate of 6.1 per 10,000; this compares to the general sector rate of only 2.1 per 10,000. As significant as these numbers are, the actual number of incidents is much higher due to the gross underreporting that is related to the persistent perception assaults are part the job.

Among health care workers, nurses and patient care assistants (PCAs) experience the highest rates of violence. Emergency department (ED) nurses experience physical assaults at the highest rate of all nurses (Crilly, Chaboyer, & Creedy, 2004). In a study of Minnesota nurses, ED nurses were over four times more likely to report they had been assaulted compared with nurses in other units (Gerberich et al., 2005). Gates, Ross, and McQueen (2006) found 67% of nurses, 63% of PCAs, and 51% of physicians had been assaulted at least once in the previous 6 months by patients. Kowalenko, Walters, Khare, and Compton (2005) found 28% of emergency physicians indicated they were the victim of a physical assault the previous 12 months. A recent national study of 3,465 ED nurses found violence is highly prevalent and prevention is dependent on commitment from hospital administrators, ED managers, and hospital security (Gacki-Smith, Juarez, & Boyett, 2009).

Violence in the health care setting affects the employee, employer, and patients. In addition to physical injury, disability, chronic pain, and muscle tension, employees who experience violence suffer psychological problems such as loss of sleep, nightmares, and flashbacks (Findorff, McGovern, Wall, Gerberich, & Alexander, 2004; Gerberich et al., 2004; Levin, Hewitt, & Misner, 1998; Simonowitz, 1996). Health care workers who are assaulted experience shortterm and long-term emotional reactions, including anger, sadness, frustration, anxiety, irritability, apathy, self-blame, and helplessness (Gates, Fitzwater, & Succop, 2003; Gillespie, Gates, Miller, & Howard, 2010; Hagen & Sayers, 1995; Pillemer & Hudson, 1993). Gates et al. (2003; 2006) found assaulted nursing assistants in long-term care were significantly more likely to suffer occupational strain, role stress, anger, job dissatisfaction, decreased feelings of safety, and fear of future assaults. Symptoms occurred regardless of whether an injury was sustained from the assault. Other researchers (Caldwell, 1992; Gerberich et al., 2004) found at-risk health care workers frequently suffer symptoms of post-traumatic stress disorder (PTSD). Laposa and Alden (2003) studied ED workers and found 12% met full criteria for PTSD, 20% met the symptom criteria for the disorder, and the proportion of workers with PTSD was significantly higher than the general population. Research by Findorff-Dennis, McGovern, Bull, and Hung (1999) indicates the consequences of workplace violence continue after a violent event, affecting quality of life for years after the event. Other researchers found patient aggression is associated with the intention to leave the job and the nursing profession (Arnetz, Arnetz, & Soderman, 1998; Ito, Eisen, Sederer, Yamada, & Tachimori, 2001). For the employer, workplace violence impacts costs related to increased turnover, absenteeism, medical and psychological care, property damage, increased security, litigation, increased workers' compensation, job dissatisfaction, and decreased morale (Banaszak-Hall & Hines, 1996; Gerberich et al., 2004; Mesirow, Klopp, & Olson, 1998). McGovern et al. (2000) found 344 nonfatal assaults cost employers inMinnesota an estimated $5,885,448; costs included medical expenditures, lost wages, legal fees, insurance administrative costs, lost fringe benefits, and household production costs. The cost per case for assaults to registered nurses was $31,643 and $17,585 for licensed practical nurses.

The authors found only a small amount of research which examines the effect violent events have on health care workers' productivity, particularly their ability to provide safe and compassionate patient care after an event. The purpose of this study was to examine how the relationship of violence from patients and visitors is related to work performance and symptoms of PTSD in ED nurses.


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