# data[].attributes.body
The National Institute for Occupational Safety and Health (2018) defines workplace violence as “violent acts (including physical assaults and threats of assaults) directed toward persons at work or on duty." Healthcare workers are particularly vulnerable to workplace violence. According to the Occupational Safety and Health Administration (OSHA) (2016), health care workers are four times more likely to be victimized than workers in private industry.

# data[].attributes.body
What is the problem?
Patient violence toward nurses
The most common type of violence in healthcare is patient/visitor to worker, accounting for 93% of assaults against healthcare workers  (The Joint Commission, 2018). The Bureau of Labor found that rates of injury from workplace violence in hospitals is increasing (Arnetz, Hamblin, Russell, Upfal, Luborasky, Janisse, & Essenmacher, 2017). Alarmingly, the rate of violent incidents is likely much higher due to underreporting (The Joint Commission, 2018).

Who is affected?
Nurses in any clinical environment are vulnerable to patient violence (Locke, Bromley, & Federspiel, 2018). Other patients in the care of the nurse may also be affected. A research article in the Journal of Nursing Scholarship found that patient violence is "detrimental to the nurses' ability to provide safe, quality care" (Roche, Diers, Duffield, & Catling-Paull, 2009).

How?
Patient violence toward nurses encompasses a spectrum of actions from verbal threats to physical assault. Hitting, kicking, beating, and shoving are the most reported incidences (Locke, Bromley, & Federspiel, 2018).

Where?
Nurses in emergency settings and inpatient psychiatric units have the highest risk of patient violence  (Locke, Bromley, & Federspiel, 2018).

When?
Common patient triggers include stressful conditions, expectations not being met, and perceived loss of control (Locke, Bromley, & Federspiel, 2018).

Why?
The Joint Commission (2018) states, "The most common characteristic exhibited by perpetrators of workplace violence is altered mental status associated with dementia, delirium, substance intoxication, or decompensated mental illness".

# data[].attributes.body
Direct adverse outcomes for the nurse that experiences patient violence:

Physical, psychological, and emotional trauma

PTSD

Burnout

Anxiety

Depression

Decreased job satisfaction

Decreased organizational commitment

Financial loss related to medical costs for injuries and inability to work

(Shea, Cooper, Cieri, Sheehan, Donohue, & Lindsey, 2018).

Direct adverse outcomes on patient care:

After a violent or aggressive incident, nurses have a reduced capacity to care for their patients, leading to disruptions in patient care (Shea, Cooper, Cieri, Sheehan, Donohue, & Lindsey, 2018).

Verbal and physical violence leads to distractions, contributing to a higher incidence of medication errors and negative patient outcomes (Locke, Bromley, & Federspiel, 2018).

Impact of patient violence of healthcare systems:

Decreased employee job performance

Decreased productivity

Increased absenteeism

(Shea, Cooper, Cieri, Sheehan, Donohue, & Lindsey, 2018).

High worker turnover

Low staff morale

Financial losses related to medical costs for physical and psychological injury, injury compensation, and loss of skilled workers

(The Joint Commission, 2018).

# data[].attributes.body
Barriers to Change

Nurses may face an ethical dilemma in reporting and/or prosecuting because they feel their assailant is not responsible for their actions due to an altered mental status (e.g., decompensated mental illness) (The Joint Commission, 2018).

Underreporting is a major barrier to changing hospital policies and state/federal laws that protect healthcare workers.

Underreporting is attributed to the mentality that violence is "part of the job"--injuries are either routine or unavoidable (OSHA, 2015). Other reasons include lack of a reporting policy, lack of faith in the reporting system, and fear of retaliation (OSHA, 2015).

Verbal assault is often not reported but is a risk factor for battery. The Joint Commission (2018) notes that, "apathy toward assaults such as verbal abuse creates an environment conducive to more serious, physical crimes."

# data[].attributes.body
Nurses' Current Role & Participation

Nursing organizations, such as the National Nurses United, are supporting the the Workplace Violence Prevention for Health Care and Social Service Workers Act (HR 1309). This bill would mandate that OSHA create a national standard requiring health care employers to develop and implement a comprehensive workplace violence prevention plan (National Nurses United, 2019).

Nurses are using social media to give a voice to the issue and share their experiences. The Silent No More Foundation works to protect and support healthcare workers through advocacy, legislation, and education (Silent No More Foundation, 2017). The organization started the #silentnomore social media campaign to raise awareness about assaults on healthcare workers.

Patience violence is reaching epidemic levels and is a growing concern for nurses. Unfortunately, the issue is currently in the national spotlight after Lynne Truxillo, RN died as a result of a patient attack and the perpetrator has been charged with manslaughter (Vincent & Thomas, 2019). Even more alarming, she finished her shift before receiving any medical treatment.

Importance of Nurse's Involvement

The death of Lynn Truxillo underscores the importance of uniting to prevent patient violence, advocating for safer hospital practices that protects workers, and providing support for victims.

Because nurses face a persistent threat of patient violence, they will will play a key role in changing the current culture that views patient violence as acceptable. Nurses must work to change this perception both within the profession and society itself.

Multiple provisions in the ANA Code of Ethics for Nurses relates to nurse's involvement in changing this issue, including:

Provision 5  states, "The nurse owes the same duties to self as to others, including the responsibility to promote health and safety, preserve wholeness of character and integrity, maintain competence, and continue personal and professional growth."

Provision 6 states, "The nurse, through individual and collective effort, establishes, maintains , and improves the ethical environment of the work settings and conditions of employment that are conducive to safe, quality health care."

Provision 7 states, "The nurse, in all roles and settings, advances the profession through research and scholarly inquiry, professional standards development, and the generation of both nursing and health policy."

Provision 8 states, "The nurse collaborates with other health professionals and the public to protect human rights, promote health diplomacy, and reduce health disparities."

(American Nurses Association, 2016)

# data[].attributes.body
1. Participate!

- Nurses can make a significant impact by advocating for change at an organizational level. Participating in committees that develop protocols and training policies will help foster a culture of safety, ultimately leading to safer outcomes for both nurses and patients.

-The American Nurses Association (ANA) recommends these best practices for building a comprehensive safety structure for your organization:

Establish incident-reporting systems to capture all violent incidents.

Create interprofessional workplace violence steering committees.

Develop organizational policies and procedures related to safety and workplace violence, as well as human resources support.

Provide workplace violence-prevention and safety education using evidence-based curriculum.

Use rapid response teams (including police, security, and protective services) to respond to violent behaviors.

Delineate violence risk indicators to proactively identify patients with these behaviors.

Create scorecards to benchmark quality indicators and outcomes.

Post accessible resources on the organization’s intranet.

(Locke, Bromley, & Federspiel, 2018).

2. Take Action!
-To inspire change on a larger scale, nurses should voice their concerns to legislators and vote in state and federal elections.

Writing legislators is an easy way for nurses to communicate their concerns and encourage their political representatives to support legislation that protects nurses and other healthcare workers. Many organizations offer template letters that can be customized.

Nurses that are registered voters can support legislative efforts, like the Workplace Violence Prevention for Health Care and Social Service Workers Act, which was re-introduced after failing in previous efforts.

-Participating in professional organizations is crucial in influencing change on a national level. These organizations work to protect nurses and foster safe work environments by providing a united voice for nurses and lobbying for state and federal support. In 2017, the ANA launched the #endnurseabuse initiative to encourage individuals to take a pledge that supports zero tolerance policies, reporting abuse against nurses, and sharing the pledge with family and friends to increase awareness of this serious issue (American Nurse Today, 2017).

3. Educate!
-While avoiding all violent encounters is impossible, nurses should educate themselves and their team about the hospital's protocols related to workplace violence, reducing environmental risks and using de-escalating techniques.

A key principle to safety is to not become complacent and be consistently aware.

If a patient is showing signs or has a history of violence, the nurse should remove objects that the patient could use to cause harm (e.g., IV poles, glass, mirrors).

Nurses should be able to recognize and understand patient triggers and predisposing factors to violence. Specific patient triggers should be shared during handoffs and safety huddles.

(Locke, Bromley, & Federspiel, 2018).

Nurses should utilize assessment tools, such as STAMP (Staring, Tone and volume of voice, Anxiety, Mumbling, and Pacing), to recognize aggressive patients.

De-escalation strategies includes therapeutic communication that is calm and non-confrontational, use of non-threatening body language, responding to patient's concerns to foster trust, and setting clear limits.

(The Joint Commission,  2019).

# data[].attributes.body
Workplace Violence Prevention and Response Policy

# data[].attributes.attachment_link.title
Workplace Violence Prevention and Response Policy

# data[].attributes.attachment_link.title
Jimmy's Story #silentnomore | ZDoggMD.com

# data[].attributes.body
Curricular Concepts

Understanding the the impact of laws and legislative processes on nursing.

Sullivan (2013) states, "Becoming active in professional associations, learning the legislative issues that affect nursing, gaining political skills, and being willing to advocate for nursing causes are necessary for the profession to flex its considerable political muscles. All nurses can participate to some extent in these activities" (p.96).

Developing interdisciplinary communication skills that promote collaborative relationships.

Collaboration communication promotes team synergy and is a central component to a culture of safety (Sullivan, 2013).

Developing therapeutic communication skills that foster trust between nurse and patient.

As ambassadors of care, nurses must understand the importance of positive therapeutic communication. This will further the positive image of both the nurse and the profession (Sullivan, 2013).

Leadership Role

As a student nurse, learning the impact of laws and legislative processes on nursing has prepared me to be an active participant in nursing politics. Even as a novice nurse, I can demonstrate leadership skills by advocating for policy changes that promote quality patient care in safe work environments.

Collaborative communication is essential when working on interdisciplinary committees that influence hospital policies and protocols. Because of the emphasis on clear and concise communication throughout the curriculum, I am prepared to effectively represent the profession of nursing and collaborate with other healthcare professionals.

By utilizing the therapeutic communication skills I learned throughout my nursing education,  I can optimize my ability to provide safe and quality patient care. As a result, I can serve as a model for my co-workers and my profession. Sullivan (2013) notes, "A nurse whose thoughtful and convincing ideas substantially influence the efficiency of work flow is exercising leadership skill" (p.41).