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The Occupation Health and Safety Act of 2019 defines workplace violence as :

"The exercise of physical force by a person against a worker, in a workplace, that causes or could cause injury to the worker; a statement or behavior that is reasonable for a worker to interpret as a threat to exercise physical force against the worker in a workplace that could cause physical injury to the worker"
(Somani et al., 2021)

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The "who, what, when, where, why and how"?

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The "who, what, when, where, why and how"?

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Who is directly affected?
Nurses go to work every day and they are faced with the possibility of being abused by their patient or patient's family member. In comparison to other professions, nurses face an even higher risk of being victims of violence than prison guards or law enforcement at work (n.a.-a,2019).

What is the concern?
The greatest concern is that one in four nurses will be a victim of workplace violence (n.a.-a,2019). However, due to the extent of barriers that nurses face when reporting incidences, countless cases go unreported (Guyre, 2019). This is leading to many nurses feeling unsafe in their place of work and the emotional burnout is creating an even more stressful work environment (Haddad et al., 2020).

When does this happen?
Those that work in healthcare and nurses, in particular, are at the highest risk for experiencing workplace violence (Somani et al., 2021). The United States Bureau of Labor reports that healthcare workers are five times more likely than any other profession to experience violence (n.a.-b, 2020). Furthermore, of all the nonfatal workplace injuries and illnesses due to violence accounted for in 2018 73% of those were healthcare workers (n.a.-b, 2020).

Why does it happen?
Extensive studies have been done to get to the bottom of why it happens so frequently in this profession. One particular study interviewed nurses and a common theme is the lack of support to provide the basic needs of patients ultimately leads to an upset that prompts the behavior (Yesiblas & Baykal, 2021). Increased workload on nurses, lack of sufficient equipment and supplies, and miscommunication among the healthcare team are just some of the reasons that are listed that agitated patients and lead them to be perpetrators of abuse towards their nurses (Yesiblas & Baykal, 2021). To make matters worse, there is a lack of consistency when it comes to policies set in place for nurses to easily report an incident (Guyre, 2019).

How does it happen?
When speaking about workplace violence it is not just the physical act of violence but can also include sexual assault or harassment, berating, and verbally threatening as well (Piche & Roche,2020).

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RISK ASSESSMENT:
There are certain factors that make a patient more likely to inflict violence if a situation brings it on and it is important for nurses to assess the patient for these factors and be aware

history of violence

substance abuse

alcohol intoxication

cognitive impairment

mental health issues

Assessing patients for these potential liabilities can help a nurse to be mindful in communication and have certain precautions already set in place.

(Piche & Roche, 2020)

COMPLEX INTERVENTION FOR A COMPLEX ISSUE:
Workplace violence is a complex problem that has multiple precipitating factors and interventions should address them all. To properly implement interventions there must be multiple components to address the environmental, administrative, and behavioral factors.
(Somani et al.,2021)

Environmental: This should include adding things such as panic buttons to rooms for nurses to push when there is a danger to call for backup. This would also put the unit on lockdown and call in security if a threat does occur to ensure the perpetrator is held accountable and put in the necessary restraints if needed.

Administrative: The protocols put in place that is consistently supported and reviewed by the administration are more likely to be successful. This means that for the interventions to be effective management must follow up and assess if the implementation is working and provide the resources and emotional support necessary.

Behavioral: An empowered and confident nurse is the most effective in de-escalating a potentially violent situation. The key components of this intervention model are education seminars that train nurses in handling workplace violence and equipping them with the communication skills and self-defense to either de-escalate or defend themselves when needed . This not only gives nurses the skills to handle these situations but also raises awareness and how to recognize the warning signs.

(Somani et al.,2021)

CALL TO ACTION:
One of the biggest reasons nurses do not file a report when an incident occurs is because of the lack of consistency when it comes to a procedure to report. This leads to a lack of data about incidences and therefore an inability to research and find the most effective interventions. How can nurses get involved?

Join a nurses' organization-- the ANA is one of the most involved organizations when it comes to advocating for legislature.

Hold management accountable-- it is important for change in the reporting process to change from the top down so that nurses feel supported when they follow through with reporting and incidents. It is crucial that nurses advocate for themselves and feel empowered!

(Guyre, 2019)

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Two curricular concepts:

1. Patient Safety:

This is a concept that throughout nursing school has become engrained in the way we think. Almost everything we do should be reverted back to how will it affect patient safety. When it comes to workplace violence and abuse from patients it can seem to contradict this concept. It is important to ensure our own personal safety before we can provide competent care for our patients. While we take an oath to do no harm to our patients it is crucial that no harm is done to us for the sake of our job.

2. Self-awareness:

When studying topics like bio-ethics and mental health we have been taught to be aware of our own biases as nurses. It is important to understand how we as nurses channel our emotions when work is difficult or there is a challenging patient. This plays into how we communicate with our patients and can make the difference in making them feel heard and de-escalating a situation that could potentially result in violence.

Leadership:

When applying these concepts to a role of leadership it is essential to recognize the importance of both the patient and the nurse providing care. This ties into having a reporting process that is uniform and ensuring all staff members are aware of this process. Furthermore, following through with all the education on the interventions that could prevent situations from turning violent. Checking in with staff members on their feelings around events will aid them in raising their self-awareness as well. Many nurses have reported that when they have stronger leadership they feel safer in their work environments (Gooch, 2017).

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Why is the nurse's involvement so important?

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Why is the nurse's involvement so important?

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"To create a violence-free environment the effectiveness of interventions depends on the involvement of all stakeholders"
(Somani et al., 2021)

The support of the admin is crucial for these interventions to work... but the nurse's autonomy and utilizing these skills are just as critical.

Just as nurses advocate for their patients this same compassion and persistency should be applied to themselves.

When nurses do not report incidences this inhibits hospitals from being able to identify the precipitating factors that lead to the violence (Somani et al., 2021). Even if hospitals set interventions in place it is up to nurses to consistently make reports and utilize safety measures. Without their direct involvement, there will be no data to see if interventions are successful or make changes where improvements can be made.

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Lack of official reports:
- One of the main issues with workplace violence is that many incidents do not get officially reported therefore there is not enough data collected to be able to fully research the exact circumstances and contributing factors.
(Guyre, 2019)

Changing the culture of acceptance:
- In no other profession do workers just expect to have to harm by another human being. Experiencing abuse, as a nurse has become unofficially embedded into the job description, and nurses, have become "desensitized" to the violence. This expectation and desensitization to the magnitude of the problem is another contributing factor to the reason there is a lack of reporting.
(Piche & Roche, 2020)

- Nurses also say they do not report because the expectation is so deeply embedded into the belief system that they fear being ridiculed by coworkers for not being able to properly perform their job.
(Guyre, 2019)

Support:
- Not only does the culture need to be shifted away from believing that violence comes with the title but also that nurses deserve the organizational support to make changes. Many nurses report feeling "unprotected" and this can be attributed to management not supporting them in the process of reporting or not taking the proper precautions to prevent the violence in the first place.
(Yesiblas & Baykal, 2021)

- After an incident has occurred it is important that nurses be given a space to process this event as well, which is not always happening. This means the administration should not only provide first aid but also follow up with counseling for everyone involved.
(Gooch, 2017)
The Future of Nursing:
- There is already a staffing crisis in hospitals. As a percentage of nurses age out of the profession, an increasing amount is reporting burnout and attributing it to the emotional stress caused by the "ever-present threat of emotional or physical abuse" (Haddad et al., 2022). The US Bureau of Labor Statistics already predicts that between 2020 and 2030 an additional 275,000 nurses will be needed to properly staff hospitals (Haddad et al., 2022). Additionally, in the United States, 35% of nurses calling out or leaving their jobs is due to the violence they experience in their workplace (Somani et al.,2021). It is crucial for the future of nursing to obtain a solution to the problem to prevent the number from growing and decrease the rates of burnout.

Impact on Patient Care:
Nurses are becoming more and more exhausted each day with the threat of experiencing workplace violence (Kim et al., 2020). This exhaustion is making it harder for them to properly meet the demands of their jobs and patient care is being compromised and there has been a correlation between negative patient outcomes and hospitals with a higher incidence of workplace violence (Kim et al., 2020

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Due to the lack of reporting there is no data to follow along with and compare any improvements in this issue.

It can be concluded however that if nurses do not play an active role with reporting cases the problem will continue to worsen.

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A vast number of nurses can recall a time that they have experienced a patient or a patient's family inflicting some level of abuse on them. However, the number of official reports does not come close to the number of actual incidents. This is because currently, nurses are not reporting. This is only perpetuates the culture created around workplace violence. If nurses continue to be complacent and stick to the mentality that "this is apart of the job" then it will continue to be apart of the job and the issue will not improve.

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The culture created in hospitals plays a direct role in changing this issue. The lack of reports can be attributed to many factors such as:

Beliefs that violence is "a part of the job"

Fear of being at fault for the violence by peers and/or management

Unclear perception of the definition of violence

Nurses not thinking the incident was serious enough to report

No uniform reporting system

Another challenge that nurses are faced with is the incident of abuse from a patient who is suffering from a condition that impairs their cognition. This can make is difficult to decipher whether or not the violence was intentional or not.

(Gruyre, 2019)

When thinking of this issue in a social context I believe not enough of the general public is aware of what nurses do every day. They become frustrated and resort to abuse towards the people who are doing the best that they can with a system that does not always give them the resources they need.