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


The results from this study support the growing literature about traumatized persons and the increasing recognition of the negative effects that traumatic events, such as violence, have on workers. In 1980, the American Psychiatric Association included PTSD in their Diagnostic and Statistical Manual Mental Disorders for the first time. It was documented that direct and indirect exposure to violence may result in serious psychological effects (Figley, 1995). It is not unusual for workers to experience anxiety after being threatened or assaulted by a patient or visitor and for a short time period afterwards. The prevalence of study participants with post-traumatic stress symptoms during the 7 days after a violent event is significant. Seven teen percent had scores high enough to be considered probable for a diagnosis of PTSD and 15% had scores associated with suppressed immune system functioning.

The results from this study supported other researchers who have found workers suffering from PTSD symptoms experience distressing emotions, difficulty think - ing, withdrawal from patients, absenteeism, and job changes (Figley, 1995; Herman, 1992; Laposa & Alden, 2003; Laposa, Alden, & Fullerton, 2003; McCann & Pearlman, 1990; 1992).

In the current study, exposure to violent events was significantly related to decreased productivity in the areas of Cognitive Demands and Support/Communication Demands. These findings suggest that whereas ED nurses report they are able to continue to maintain their usual pace of work and provide safe and competent care, they have more trouble remaining cognitively and emotionally focused while working after a violent event.

The correlation between the total Healthcare Productivity Survey and Impact of Event Scale- Revised scores was close to reaching statistical significance. Each of the three Impact of Event Scale-Revised scores and the total Impact of Event Scale-Revised score were highly significantly related to the Cognitive Demands and Support/Communication Demands. The more stress symptoms reported by a participant, the more difficulty the ED nurse had with these two areas of productivity. The hyperarousal criterion is a manifestation of dysregulation of the stress-response system and persons with these symptoms are often quick to react with irritability, hostility, anger, and anxiety (Wilson, 2004). These symptoms are likely to have an impact on the ability of the nurse to communicate with patients and visitors, and to provide emotional support when they themselves are in need of such support. It is also possible those with hyperarousal symptoms would have difficulty thinking, concentrating, and with other cognitive functions (Wilson, 2004).

Persons with avoidance symptoms often experience feelings of detachment, and may distance themselves from others. They may have a decreased capacity for tolerating or experiencing emotions. While these efforts serve as a coping mechanism to control hyperarousal symptoms, they can affect the nurse's ability to relate to her or his patients and co-workers.

Intrusion symptoms are characterized by nightmares and visual images of the trauma event itself or its aftermath. The mean for intrusion symptoms was the highest of the three scales, indicating the highest frequency of participants experiencing the symptoms. This could be due to the fact the participant has to return to the place (the ED) where the event occurred. It is likely intrusion symptoms would impact the nurse's ability to concentrate and to provide compassionate care. Health care providers admit that after violent experiences they tend to avoid patients who have been or might be violent (Gates, Fitzwater, & Meyer, 1999; Gillespie et al., 2010).

At first review it is remarkable the PTSD symptoms were not significantly related to productivity areas of Workload and Safe/Competent Care Demands. There are two possible explanations for this finding. First, participants may not have felt comfortable admitting to unsafe behaviors on a survey or may not even be consciously aware they had changes in performance. Second, an understanding of both the characteristics of ED nurses and the type of work they provide may help to explain these findings. Emergency department nurses are experienced and trained to provide care to patients often in very stressful situations. This includes working under extreme time pressures while taking care of acutely ill patients often without any or a complete diagnosis. ED nurses work in fast-paced environments and because emergency departments are often overcrowded, ED nurses become adept at multitasking to prioritize their patient care and their time. There is a body of research showing well-learned tasks are more resistant to the negative effects of stress (Beilock, Carr, MacMahon, & Starkes, 2002; Bracco, Giannetti, & Pisano, 2010). This phenomenon is often refer red to as cognitive resilience, which is the capacity to overcome the negative aspects of an event and its associated stress on cognitive function or performance. The level of cognitive processing for completing routine patient care does not require a lot of attention resources since the required skills and procedures are repetitive actions that have been highly honed by ED nurses. These quickly performed skills are often executed "more automatically." In contrast, emergency nurses are likely to have more difficulty coping with unfamiliar and unpredicted events such as violence for which few have any or little training on how to prevent or manage. This reduced capacity to cope is likely to result in greater difficulty in managing higher-level work demands that require concentration, attention to detail, or communication skills.

Researchers found that as the mental health of workers with PTSD improved, productivity also improved. Immediate interventions, during the first hours or days after a trauma, can provide the victim with the support system currently lacking in most health care facilities. Implemen tation of a critical incident stress debriefing (CISD) can prevent the more serious, long-term complications associated with exposure to traumatic events (Flannery & Everly, 2000; Kaplan, Iancu, & Bodner, 2001). By providing a support system composed of peers and administrative representatives, employees have an opportunity to process the event and put it into perspective (Antai-Otong, 2001), thus minimizing the short and long-term symptoms related to stress and anxiety (Flannery & Everly, 2000; Kaplan et al., 2001; Mitchell, 2000). Such interventions would help alleviate the stress for the nurse but also has the potential to improve the quality of care received by patients.

Nurses admit that unless they are physically injured, they are often expected to return immediately to their work after being physically assaulted by a patient or visitor (Emergency Nurses Association, 2010; Gates et al., 2011). Most nurses do not report violent incidents believing that reporting does not make any difference since violence is expected and tolerated, that incidents are seen as a sign of their incompetence, or that they might encounter retaliation by ED management and hospital administration. Executives may feel such reports have a negative effect on patient satisfaction reports. This ED culture contributes to the belief ED nurses need to be tough, resilient, and are not easily intimidated or shaken by stressful events. (Emergency Nurses Association, 2010; Gacki-Smith et al., 2009; Gates et al., 2006; Gates et al., 2011). In a recent focus study by Gates et al. (2011), a participant stated "it's not a good day in the ED if you haven't been verbally abused…or someone's taken a swing at you." Another quote during this same study by a nurse was: "You need to walk away for a minute and then you have to put your game face back on and get back out there."

Few ED nurses report they participated in any formal or informal debriefing after a violent event (Gates et al., 2006; Gates et al., 2011). This lack of attention to the emotional effects of violence can contribute to PTSD symptoms. Nurse administrators need to recognize the impact violence against health care workers has costs related to increased turn over, absenteeism, medical and psychological care, property damage, increased security, litigation, increased workers' compensation, job dissatisfaction, and decreased morale. In addition, the results of this study provided new data about the productivity losses due to performance changes that often occur after a nurse is assaulted. Nurse managers need to recognize many ED nurses experience stress symptoms due to violence and seek to recognize and refer them for counseling or forms of support. The Joint Commission (2010) recently re - leased a Sentinel Event Alert related to the increasing violence in the health care setting and the steps that hospital administrators and managers need to take to protect both employees and patients.


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