The recent #MeToo movement has certainly brought violence against women into the media spotlight. This crusade has highlighted the importance of not only speaking out against such acts that were once kept quiet but also offers solutions for protecting those who could potentially fall victim to these criminal behaviors. However, violent and abusive acts against nurses are still going underreported. As nursing remains a predominately female (87%) profession, healthcare leaders must address the prevalence of workplace violence against nurses to create environments where these behaviors are no longer accepted as part of the inherent risk to the profession of nursing.

How Many Nurses Experience Violence On the Job?

A 2014 research article in the Journal of Emergency Nursing titled "Incidence and Cost of Nurse Workplace Violence Perpetrated by Hospital Patients or Visitors" reported that 76% of surveyed nurses had experienced a level of violence within the past year, with nearly 33% having been physically assaulted. Nurses working in the emergency department (ED) reported the highest incident of abuse compared to other nursing specialties, which is not surprising considering the prevalence of mental illness and the high-stress environment for patients, families, and the staff. While only 2% of nurses who report injuries actually seek treatment, costing an organization around $94,000 a year, the costs related to staff turnover or high incidences of nurses calling out ill as it relates to working in a fearful environment go unmeasured.

As a seasoned ED nurse, Debra Littlefield, BSN, RN believes that the levels of violence are escalating. "Lack of capacity in the hospital means patients are being boarded in the ED hallways for sometimes days at a time. Also, the volume of psychiatric patients, who can be very unpredictable in their behaviors, are increasing in the ED which can put the staff at risk for violence. The verbal abuse, profanity and racial slurs have always been present, but the overall violence is getting worse. For example, we had allowed a family to gather in a conference room while their loved one was being treated. When the family learned that the patient had passed, they completely destroyed the conference room. Without strong leadership, the ED can become a toxic environment very quickly."

How Can Nurses Be Kept Safe

There are many ways an organization can address violence against nurses. Hillary R. Mitchell, MSN, RN, NEA-BC has worked as both a staff nurse and nursing administrator for large organizations in Northern California. "Our frontline nurses, doctors, and techs are the best resources we have in understanding the reality of this growing risk to the overall sustainability of the healthcare team. We MUST engage our frontline in efforts that prevent violence, that practice readiness, and debrief the near-misses, to understand how we can continually improve. A SAFE nurse is a working nurse…without the SAFE nurse, there isn't a nurse to provide care. Team safety must be the primary goal to ensure that we are ready and prepared to care for patients."

In addition to engaging the staff, Mitchell states there are many things an organization can do to prevent and support nurses in avoiding violence. "First and foremost, the organization must adopt a zero-tolerance policy for violence against staff. This must be well-publicized, despite the impression patients may have, that there will be no exceptions for violence. One of the ways the EDs have done this is through posting signs published by the American College of Emergency Physicians (ACEP) within the Emergency Department. This sets the expectation for the patients and their visitors from the moment they enter the lobby, in the care areas, in waiting areas, and just about anywhere in between."

Mitchell also recommends that nursing administration should enact the following processes, based on ACEP guidelines and recommendations:

  • Strict policies in staffing patterns to prevent personnel from working alone and to minimize patient waiting times
  • Restrict the movement of the public in hospitals by card-controlled access.
  • Develop a system for alerting security personnel when violence is threatened such as panic/duress alarms, closed-circuit video recording, and emergency codes related to safety (such as Code Grey, Code Orange, etc.)
  • Flag charts of high-risk patients
  • Create a Threat Management Leadership Team that reviews and provides recommendations around patient interactions that are threatening or have intent to harm. This group should meet monthly to report out on findings, trends, and next steps for scenarios reported in the medical center.

Training for Nurses in High-Risk Environments

Nurses working in at-risk areas should undergo mandatory de-escalation training as required in some states, such as California, to head-off those people who may be exhibiting signs of violence. When staff is trained in what to look out for, or how to communicate in a non-threatening manner, outcomes are improved. Tina Nixon, MSN, RN, FNP, a staff nurse in a busy ED states that, in spite of her years of working in a high-risk area for violence, she has never been assaulted. "It's all about your attitude and how you handle your surroundings. I handle all situations with safety for the patients, family members, and myself in mind. In our shift huddles we review safety tips, we have a safety committee, and employees also share safety hazards that have happened so we may all learn. I assess each situation, patient, and family member as they arrive at a room or care area. For example, if it is a disabled patient or elderly individual, I ask the family member if there is anything I need to be concerned about, i.e. biting, hitting, or anything that might frighten or upset the patient."

Nixon also has tips for managing frequent psychiatric patients at her facility. "I am consciously aware of my surroundings, the patient's behavior or mood, and their psychiatric history. I assess the environment for any hazards that could be potentially dangerous to the patient, the family member, the security staff, or myself. When walking a patient to the restroom, I walk behind the patient at least 3 feet, not in front or on the side of them. I always try to stay at least a couple of arm lengths from the patient when providing care in regard to delivering their meals, assessing their mental status and their capacity to be educated, and their ability to understand what is expected of them while they are with us in the emergency department and what they should expect while they are under our care. I never turn my back or put myself in a corner, especially if there's any kind of concern for violent behavior. If a patient starts to become violent, I never try to handle it on my own – I always call for help."

Working Together to Minimize Violent Incidents

Acts of violence against nurses can be diminished through a multi-pronged approach. First, staff must believe that their reports of unacceptable behaviors will be addressed by the organization's leadership team. Next, organizations can adopt and publicize zero-tolerance policies for threatening behaviors. Finally, staff should be trained and frequently refreshed on de-escalation techniques, including utilizing empathetic communication, which studies have shown can decrease incidents of violence. Mitchell concludes, "As an organization, we need to be prepared. We need to practice managing difficult situations. We need to investigate not only every incident but every near-miss. We need to consistently report events to OSHA to track any trends. We need to do all of this, at minimum, in order to continually improve in creating sustainable and safe healthcare teams."

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