Step Away From That Nurse! Violence in Healthcare Continues Unabated

Laura A. Stokowski, RN, MS

Disclosures

November 19, 2014

In This Article

Harassment to Homicide

If you have been a victim of workplace violence, you know what it is and what it feels like. Workplace violence is any physical assault, threatening behavior, or verbal abuse directed at those who are at work or on duty.[25] Violence includes overt and covert behaviors ranging in aggressiveness from verbal harassment to homicide.

Workplace violence can have both physical and psychological effects on the victim.Although the workplace violence "umbrella" also includes worker-to-worker (lateral or horizontal) violence, this article focuses on violence perpetrated by patients, family members, visitors, or other strangers in the healthcare setting.

When Dan Hartley, EdD, workplace violence prevention coordinator at the National Institute for Occupational Safety and Health (NIOSH), is speaking to nursing groups, he wants to find out how many nurses in the audience have experienced workplace violence. "I've learned to say, 'Raise your hand if you have never experienced workplace violence,'" says Hartley. "It's much easier to count the hands because so few of them go up."

What Do the Numbers Say?

Although no one disputes the fact that violence occurs in healthcare, we are still hampered by a dearth of firm statistics about the prevalence of workplace violence in healthcare settings. Data are collected from the Bureau of Labor Statistics (BLS) only on episodes of nonfatal violence that result in days lost from work—in other words, episodes that are reported and cause sufficient injury for the nurse to take time off from work.

However, surveys of nurses about their experiences with workplace violence suggest that, as a rule, only the most serious incidents are reported. Many nurses neglect to report workplace violence if they haven't been physically harmed, if they "excuse" the perpetrator's behavior for some reason, or if they believe that it is unlikely to be repeated (because the patient or visitor is gone from the facility, for example, or the nurse is not scheduled to work the following day).

Bearing in mind that they severely underestimate the prevalence of workplace violence involving nurses, the few available statistics can do no more than hint at the scope of the problem, but they do suggest that violence is increasing rather than decreasing.

BLS keeps statistics on the number of nonfatal workplace injuries that required days off from work. In 2012, a total of 19,360 episodes of violence or other injuries inflicted by persons or animals were reported in healthcare and social assistance, almost equally divided between acts that were intentional and those that were considered unintentional or intent unknown.[26] This equates to a rate of 15.1 incidents per 10,000 full-time workers,[27] and it represented a 6% increase in violence against healthcare and social assistance workers.[28] When broken down by healthcare setting, 5910 incidents occurred in hospitals (15.6 per 10,000), 8990 in nursing or residential care facilities (37.1 per 10,000), and 1790 (3.7 per 10,000) in ambulatory care centers and offices.[27] Considering reports by provider type, in 2012, a total of 2160 episodes of workplace violence against registered nurses and 780 against licensed practical/vocational nurses were reported.[29]

Most likely, these data underrepresent true rates of nonfatal workplace violence. We know from survey data of nurses that workplace violence is common. A recent survey of 764 primarily white, female nurses employed by a large, multihospital urban/community hospital system asked nurses how often they experienced episodes of physical or verbal violence, and what they believed to be the causes of these incidents.[30] The survey response rate was 15.2%. During the past year, 76% experienced violence (verbal abuse by patients, 54.2%; physical abuse by patients, 29.9%; verbal abuse by visitors, 32.9%; and physical abuse by visitors, 3.5%), such as shouting or yelling, swearing or cursing, grabbing, scratching, or kicking. Emergency nurses (12.1%) experienced a significantly greater number of incidents (P < .001). The perpetrators were primarily white male patients, aged 26-35 years, who were confused or influenced by alcohol or drugs.

Do Nurses Report Workplace Violence?

Nurses were also asked whether they reported these incidents of violence; reasons cited for not reporting included not sustaining physical injury (49.5%), inconvenience (26.1%), and the perception that violence comes with the job (19.6%). Other prominent reasons included being unclear about reporting policies, not wanting to draw attention to oneself, and fear of retaliation or reprisals. Other evidence confirms that many nurses take a fatalistic view of reporting workplace violence. They believe that reporting it is a waste of time, and nothing will be done about it anyway.[13]

Hartley finds another reason that some nurses don't report workplace violence. "Some nurses don't understand what constitutes workplace violence. A patient might strike out at a nurse while he or she is giving a med, but that happens all the time. Or nurses say that they only report violent behavior if they have to go the ED." Hartley tells of a nurse who worked in a nursing home who had an "aha moment" at a workplace violence seminar. "I never thought of being hit, kicked, or spit on by patients as violence, until I realized one day that it was the same patients doing it over and over again. We weren't reporting it, so no one pinpointed the problem and nothing was ever done."

Workplace violence can, and has, happened in any area of healthcare. Although it is most frequent in three areas—the ED, mental health settings, and geriatric care—no healthcare setting is immune. Violence toward nurses has happened in labor and delivery, pediatrics, and ambulatory care. It happens in patients' rooms, waiting rooms, and even in patients' homes. Workplace violence affects all healthcare workers, but nurses are the most likely to be assaulted on the job.[31]

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