Step Away From That Nurse! Violence in Healthcare Continues Unabated

Laura A. Stokowski, RN, MS


November 19, 2014

In This Article

Can Healthcare Violence Be Predicted?

It would be unrealistic to suggest that violence can ever be completely eradicated from the healthcare environment however many zero-tolerance policies are implemented. When people are sick or injured, emotions run high. People are stressed, anxious, and unhappy. A more productive approach is to identify the behavioral cues that might foretell violent behavior, and the situations most likely to precipitate violence, in line with the philosophy that "forewarned is forearmed."

Picking up on the behavioral cues for violence has obvious benefits for the individuals in the line of fire, and an increased awareness about the catalysts for violence can help healthcare facilities bolster their security and response mechanisms. Electronic health records and data entry have made this type of analysis possible, but the benefits will be realized only if nurses and others are encouraged to make reports for every incident of workplace violence, regardless of whether physical injury occurs or the perceived intent of the action.

A recent study[33] assessed the situational factors that seemed to most frequently precede violent behavior on the part of patients toward nursing staff. Using data from a centralized reporting system, all incidents (n = 214) during a single year (2011) at an urban hospital were analyzed. These incidents were reported by nurses (39.8%), security staff (15.9%), and nurse assistants (14.4%). Incidents of violence were found to be linked to specific patient characteristics and behaviors (cognitive impairment, pain or discomfort, demanding to leave), patient care (use of needles, use of restraints, physical transfer of patients), or situational factors (transitions in care, intervening to protect patients or staff, and redirecting patients).

Another study[34] supports the fact that psychiatric and geriatric settings are prone to violence against nurses. A survey of 284 nurses working in locked psychiatric units demonstrated a rate of verbal aggression of 0.6 incident per nurse per week, and 0.19 incident per nurse per week for physical aggression. Episodes of violence were significantly more common on the evening shift (compared with the day shift), and having more patients with personality disorders was associated with higher rates of verbal and physical aggression.

An observational study[35] in an acute care geriatric ward targeted the behavioral cues that might serve as warning signs for episodes of violence among elderly patients. Pacing around the bed universally preceded episodes of violent behavior, and all patients who became violent had previously demonstrated shoving behavior.

Just as important as the number and features of reported incidents, however, is how nurses feel at work. Do they feel safe, or are they frequently concerned about personal safety? Do they experience perceived threats, even if these don't materialize into violence? A study[36] in a pediatric ED found that 26% of nurses were concerned for their safety at least weekly, and that the primary causes for their anxiety were patient or visitor agitation (with violence potential) and weapons in the ED. Most nurses believed that having a greater presence of security personnel or local police would increase their feelings of safety at work.

A new tool assesses perceptions of personal safety of nurses. Burchill[37] designed and pilot-tested a survey instrument, the Personal Workplace Safety Instrument for Emergency Nurses (PWSI EN), which was found to have high content validity for identifying the factors that make nurses feel safe or unsafe at work.


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