Nurses Exposed to Increasing Violence
By Debra Wood, RN, contributor
Emergency nurses never know what patient they will encounter next and these days they cannot ignore the possibility of violence from these patients and the people who accompany them. Workplace violence has long been a problem in nursing, but with this violence on the rise more concern must be given to nurse safety in the workplace.
“Across the United States, in Europe and around the globe, health care workers are increasingly at risk of being assaulted,” said Bill Briggs, RN, MSN, CEN, FAEN, president-elect of the Emergency Nurses Association (ENA).
“Nurses are particularly vulnerable because they spend the most time with patients,” Briggs added. “Emergency nurses are especially at risk, because they are so accessible to patients who may have abused alcohol and drugs, who are in severe distress, or who may be floridly psychotic and paranoid. In addition, families and friends of emergency patients are often frustrated and afraid for loved ones because of long waits and crowded emergency departments.”
Two-thirds of nurses working in emergency departments report an increasing level of violence, according to a 2007 Emergency Nurses Association survey. Lara Boyett, RN, MSN, ACNP-BC, CEN, and Linda Robinson, RN, BSN, CEN, CFN, presented the results of the survey of 3,465 registered nurse members at the organization’s annual conference in September 2008.
The study also found more than a quarter of emergency department nurses report experiencing physical violence 20 or more times in the past three years, 70 percent report being verbally abused more than 200 times in the past three years, and about half of those surveyed feel that violence is simply part of their practice.
“Violence shouldn’t be part of any job,” said Kate McPhaul, RN, PhD, MPH, assistant professor at the Work and Health Research Center at the University of Maryland School of Nursing in Baltimore. She indicated many nurses incorrectly believe that there is nothing that can prevent it, yet they can protect themselves and make safety a priority.
“Nurses owe it to themselves to treat themselves gently and to take care of themselves to have a safe work environment,” added Nancy Hughes, MS, RN, director of the Center for Occupational and Environmental Health at the American Nurses Association (ANA). The ANA considers workplace violence a major concern and has placed a prevention brochure on its Web site.
The ENA nurses surveyed reported being hit, kicked, pinched, pushed, scratched and spit on. Twenty had been shot or shot at, 31 stabbed, and 102 sexually assaulted. Ninety-five percent or more had been sworn at, yelled at or called names.
“Emergency nurses have described very serious injuries which leave them not only with physical sequelae, but also ongoing fear, depression and post traumatic stress disorders,” Briggs said.
These injuries and their emotional fallout often lead nurses to change jobs. Their families often encourage them to choose a safer environment.
“Given the global shortage of nurses, we can't afford to lose one nurse because they are afraid to be at work,” Briggs said. “And we know, anecdotally, that in some instances, nurses have decided not to return to nursing after an assault.”
Although nurses often file incident reports after a physical attack, McPhaul says, “No one is collecting data on the nasty, threatening behavior. I think it is demoralizing. It takes a toll and increases the fear.”
Contributing factors, according to the ENA nurses, include drug-seeking behavior, the influence of alcohol or illicit drugs, psychiatric patients, crowding and high patient volume, and prolonged wait times.
“The bottom line is you cannot make people wait two, three, eight, ten hours,” McPhaul said. “There will be more stresses and more angry people the longer the wait.”
The U.S. Bureau of Labor Statistics reports occupational assaults and violent acts increased by 10 percent in 2006 across all industries, with those to women increasing 21 percent to 10,400 cases. Sixty percent of the assaults and violent acts occurred in health care and social assistance jobs, and mainly involved assaults by health care patients.
“What we see in the federal data is the tip of the iceberg, because most of those data are severe lost work-time injuries,” said McPhaul, who is not convinced violence has increased but believes the situation is receiving more attention. She added that nurses in some regions, such as Massachusetts, have taken an active role in addressing the issue.
“It’s a huge problem, probably the biggest issue we deal with,” said Evie Bain, RN, MEd, COHN-S, associate director/coordinator at the Massachusetts Nurses Association (MNA) in Boston. “It’s hard to get a handle on the frequency.”
Nurses often fear being blamed for the assault or that a supervisor will think they don’t have the skills to properly deal with their patients. Yet uniform reporting would help nursing leaders better understand the situation and formulate solutions.
“Reporting is absolutely crucial because violence can’t be stopped if it’s an invisible secret,” Briggs said. “When reports go to management, risk management, legal and security departments, let alone federal agencies, consciousness is raised, the problem is made visible to those who have an obligation, a vested interest and the power to make changes.”
Emergency departments have developed various interventions to deal with violent patients, family members and visitors.
“There is not one single thing you can do,” McPhaul said. “You need a very comprehensive approach.”
This kind of approach will require a culture change to one in which violence will not be tolerated and should not be considered part of the job, McPhaul said. In addition, she recommends competent security guards, cameras, architectural changes to waiting areas and monitoring whether the actions taken are working.
The ENA nurses said they want around-the-clock, armed and competent security or law enforcement officers dedicated to the emergency department, zero-tolerance policies, locked doors, metal detectors and supportive management.
Only 13 percent of nurses responding to the ENA survey thought security was available an adequate amount of time. Fifty-four percent of the nurses worked in facilities with security personnel stationed in the ED, and 64 percent of facilities provide around-the-clock security personnel.
Arrowhead Regional Medical Center in San Bernardino, California, added metal detectors and highly visible security personnel in the ED and took steps to improve patient flow, which has cut the average waiting time in half—from 80 minutes to 39 minutes,. The result has been a decrease in the number of violent incidents.
McPhaul said that many hospitals want to create a warm and inviting atmosphere, rather than the negative perceptions generated by guards and metal detectors. She urges a balance, creating a friendly environment, but also putting in place programs to create a safer workplace.
In Massachusetts, some hospitals have laid off security officers, at a time when the departments need well-trained guards so that nurses can concentrate on patient care, Bain said.
Nearly three-quarters of the ENA respondents had taken some violence prevention training at their current hospital or another facility. Briggs said nurses need more training on nonviolent crisis-intervention techniques, in order to identify an escalating situation and know how to defuse it.
“Caring for the violent patient requires an organized team approach that has been planned and drilled long before the event,” Briggs said. “This can all start with one nurse making a stand.”
Caritas Good Samaritan Medical Center in Brockton, Massachusetts, received a $25,000 grant from the Department of Industrial Accidents to educate nearly 200 employees on ways to respond to and handle incidences of workplace violence. They will learn safety rules, ways to hinder an attack, how to safely escape, verbalization skills and body targets.
“I think it’s an excellent idea. I think it will help very much” said Debbie Hayes, RN, an ED nurse at Caritas for the past 18 years, in a written statement.
Hughes called such training key for nurses, so they can learn to protect themselves and recognize when incidents are getting out of control.
In addition, legislative action might help. The MNA has supported legislation that would increase penalties for crimes against nurses and other health care workers, and a second bill to require hospitals to develop risk-assessment and prevention programs. Nurses have testified and contacted their legislators to garner support for the changes. The association has also received support from police departments and district attorneys.
Ninety-nine percent of nurses in the ENA survey support stiffer penalties for violence against RNs, yet 53 percent were not aware if their state already has such laws.
Briggs encourages nurses to work on the issue through their nursing associations.
While many ideas exist for decreasing violence in EDs, McPhaul said what is truly needed is intervention effectiveness studies, so hospitals and health professionals have data to support initiatives. She also endorses more regulation targeted at staff safety and feels it should be part of the effort to reform health care.
“I don’t see hospitals voluntarily fixing this without a lot of pressure or a law,” McPhaul said. “If nurses would just get more political and push back, I think they have a tremendous amount of leverage, which they are not using.”
Many hospitals and nurse advocacy groups are taking steps to decrease workplace violence in nursing, but the threat of violent patients is not the only problem nurses face. Many nurses also suffer from lateral violence in nursing.
Nurses must take an active role in preventing workplace violence. Look into organizations near you that promote safer workplaces or talk to your supervisor if you feel unsafe. Whether it is facing violence from a patient or lateral violence from another nurse, speak up and work to improve your workplace for yourself and your colleges.
If you are looking to change hospitals or just want to try out a new location, consider travel nursing.