Health care workers must routinely handle patients who are delirious, agitated, and even aggressive, especially on psychiatric units, in EDs, and in nursing homes. Recent studies and news reports suggest that when agitation escalates into full-blown assault, nurses are often the victims. Accordingly, nurses from around the world are protesting what they say are inadequate protections in the workplace.
The issue received international media attention late last year. Australian nursing researchers Gerald Farrell and colleagues reported in the September 2006 issue of the Journal of Advanced Nursing that in 2002, almost 64% of 2,400 Tasmanian nurses said that they had suffered either verbal or physical abuse during the four weeks prior to the survey. Psychiatric and emergency settings were among those showing the highest levels of abuse. Patients perpetrated the vast majority of instances of physical (97%) and verbal (74%) abuse; other sources were visitors and colleagues. (The researchers noted that nurses ranked workload, not workplace abuse, as the most distressing aspect of the job.)
Perhaps more surprising were nurses' responses to the abuse. Of those physically assaulted on the job, 38% talked with a colleague afterward, and only 19% filed a formal report. The researchers posit that so few nurses report abuse in part because they "do not feel supported by their managers or administrators when incidents arise."
Many other recent studies also show a high incidence of workplace violence (see Nurses, Violence, and the Literature, page 26). In October 2006 the Emergency Nurses Association announced that in a telephone survey of 1,000 members, 86% reported having been the victim of workplace violence within the previous three years, and almost 20% said it was a frequent occurrence. Nonetheless, 75% predicted they still would be nurses in 10 years.
The World Health Organization (WHO), the International Labour Office, the International Council of Nurses, and Public Services International collaborated in 2000 to study the global implications of and approaches to the problem. In 2002 they released Framework Guidelines for Addressing Workplace Violence in the Health Sector (for links to the report go to http://www.who.int/violence_injury_prevention/violence/activities/workplace/en/i). Violence in health care settings is a global issue, according to the report, that particularly threatens access to primary health care in developing countries, which already suffer shortages of health care workers. Underreporting of violence is also a widespread problem, the WHO report says, perhaps because workers see the abuse as an expression of patients' illnesses or as an acceptable part of the job. Another reason for the underreporting "is work pressures that do not allow time for staff to report."
The problem is prevalent in the United States as well. The Bureau of Labor Statistics reports that 7% of workplace injuries to nursing, psychiatric, and home health aides between 1995 and 2004 resulted from assaults; for all workers over the same period, assault caused only 1% of injuries.
So who's responsible? Kathleen D. Sanford, MA, RN, FACHE, immediate past president of the American Organization of Nurse Executives (AONE), a subsidiary of the American Hospital Association (AHA), says that the AONE recommends that nurse administrators possess certain "competencies" that include being able to recognize and defuse potential conflicts before they erupt. But, she says, "the nurse has a responsibility to report abuse and to learn how to deal with it," just as the administrator bears responsibility for adherence to standards that ensure a safe environment for both staff and patients. Patients must also understand their responsibilities. "Many AHA hospitals have patient-responsibility statements like treating roommates or other patients and your caregivers well," she says.
Sanford also says that at some hospitals nurses can "call a code for violence," eliciting a response similar to that of a rapid response team. "Anyone on that team would be required to have training to de-escalate the situation," she says. It has worked in 80% of cases, Sanford says of her experience as an administrator; when it doesn't work, she says, soft restraints or medication may be used to calm someone. "It truly is about protecting the patient and the people around the patient," she says.
What should the victim do? Many nursing advocates say that all nurses who are victims of work-related physical assault should file a criminal report with the police and hold the perpetrators accountable. The Massachusetts Nurses Association identifies on its Web site (http://www.massnurses.org) several other things that victims of any type of abuse should do, such as the following:
* Don't be silent; speak about what has happened to managers and coworkers.
* Photograph any injuries.
* Work with hospital administrators and union representatives to formulate procedures, such as "algorithms for prevention and intervention."
* Ask witnesses to document what they saw.
* Be cautious with patients known to have a history of violence.
But some nurses are saying that they don't see this type of workplace support. Australian nurses have been especially vocal on the Internet. "It amazes me how lightly violence against nurses is taken," writes Amanda, an Australian contributor to an online discussion of the problem at http://www.stopviolenceagainstnurses.com. "We deserve appropriate backup, assistance, and debriefing from [hospital administrators,] which we do not get. Getting assaulted is NOT in our job description!!"
Psychiatric nurse Stephen Murphy of New South Wales (NSW), Australia, launched the Web site in October 2006 "to provide a voice for those nurses who otherwise would not be heard." Murphy claims to have been the victim of two "life-threatening assaults" on the job: one was a kick to the chest that resulted in cardiac arrhythmia and he was unable to work last year for several months because of posttraumatic stress disorder. His worker's compensation claims have been denied, but he's challenging the decision with the help of the NSW Nurses' Association.
Nurses, Violence, and the Literature
A review of some recent articles and studies.
* Alexy EM, Hutchins JA. Workplace violence: a primer for critical care nurses.Crit Care Nurs Clin North Am2006;18(3):305-12. This article defines "workplace violence" in broad terms (including bullying) and examines several cases illustrating worker-on-worker and other types of abuse in ICUs.
* Hegney D, et al. Workplace violence in Queensland, Australia: the results of a comparative study.Int J Nurs Pract2006;12(4):220-31. A 2004 survey of 3,000 nurses showed increasing rates of workplace violence, compared with the results of a 2001 survey.
* Inoue M, et al. Psychological impact of verbal abuse and violence by patients on nurses working in psychiatric departments.Psychiatry Clin Neurosci2006;60(1):29-36. Of 225 psychiatric nurses surveyed in Japan, 62% reported having been abused; of those, 21% "may have experienced posttraumatic stress symptoms" or other serious psychological sequelae.
* Anonymous. The aftermath of workplace violence: one person's account.J Emerg Nurs2005;31(6):564-6. According to this unsigned first-person account of a nurse assaulted in an ED, the assailant was sentenced to 18 months in jail.
* Luck L, et al. Survival of the fittest, or socially constructed phenomena? Theoretical understandings of aggression and violence towards nurses.Contemp Nurse2006;21(2):251-63. The authors present theories of why workplace aggression occurs and analyze the prevailing belief that violence is "a part of nursing."
* Oztunc G. Examination of incidents of workplace verbal abuse against nurses.J Nurs Care Qual2006;21(4):360-5. Of 233 nurses surveyed in Turkey, 80% reported having been verbally abused in the previous year. The highest rates were in ICUs and outpatient clinics, and there was no formal system for reporting abuse.
* Pejic AR. Verbal abuse: a problem for pediatric nurses.Pediatr Nurs2005;31(4):271-9. A descriptive study of 35 Canadian pediatric nurses found that 94% had experienced verbal abuse in the previous three months; yelling was the most common form.
* Pryor J. What do nurses do in response to their predictions of aggression?J Neurosci Nurs2006;38(3):177-82. A survey of 28 nurses working with brain-injured patients showed that when nurses can predict which patients are likely to be aggressive, preventive interventions can be planned.