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What is workplace violence?
According to the Occupational Safety and Health Administration (OSHA), workplace violence is defined as any act or threat of physical violence, harassment, intimidation, or other threatening disruptive behavior that occurs on the worksite. It can range from threats and verbal abuse to physical assaults and even homicide. The impact of workplace violence can range from psychological issues to physical injury, or even death.
(United States Department of Labor, 2022)

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Capstone Project: Introduction to Workplace Violence in Healthcare

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What is the problem?
The frequency of workplace violence has increased significantly in hospitals across several countries, with short- and long-term effects on workers' health. Within the healthcare sector, nurses are the most exposed to violence, since they provide direct patient care on a 24-hour basis.
(Bernardes et al., 2021)

Who is affected?
Workplace violence can affect and involve nurses, patients, family members, visitors, other healthcare staff, and bystanders to the incident.

How?
The American Psychiatric Nurses Association (APNA)(Kim et al., 2021) states that nurses are primarily affected by two types of violence: physical aggression, or specific actions by patients or family members towards nurses that are intended to inflict pain, bodily harm, or death; and verbal aggression, or invectives expressed by patients or family members towards nurses that are intended to inflict psychological harm through humiliation, devaluation/degradation, or threats. Acts of violence may leave nurses with disabling injuries, psychological issues, and even death. Nurses report that events of violence have negatively impacted their emotional exhaustion, perception of patient safety, and mental health creating issues such as anxiety, insomnia, and symptoms of burnout (Bernardes et al., 2021). Nurses also report lower job satisfaction and feeling unsafe returning to work.

Where?
Workplace violence can occur in any hospital on any unit around the globe. The healthcare departments where workers are thought to have the highest risk of exposure to violence are psychiatric, geriatrics, and emergency departments.
(Bernardes et al., 2021).

When?
Workplace violence against nurses has been around since the beginning of the profession. Most recently, in 2020, the Bureau of Labor and Statistics reported the incidence rate for nursing and personal care facility workers was 21.8 (out of 10,000 full-time workers) for injuries resulting from assaults and violent acts by other persons (NIOSH, 2020).

Why?
Research suggests that workplace violence is especially prevalent in the healthcare sector due to occupational characteristics such as long hours, shift work, frequent contact with death, and the lack of human resources, materials, and equipment. Other contributing factors include work overload, waiting times, and nurse-patient relations. It is also important to note that working directly with people who have a history of violence and drug or alcohol abuse in regions with high crime rates increases the risk of exposure to workplace violence by patients and their families.
(Bernardes et al., 2021)

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National Nurses United Supports Bill Against Workplace Violence

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National Nurses United Supports Bill Against Workplace Violence

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The Numbers are Telling
Most studies have shown that workplace violence has reached a very critical juncture. From 2016 to 2020 there were 207 deaths due to violence in the workplace in the healthcare and social assistance industry according to the Bureau of Labor and Statistics (BLS). In 2020, the BLS released a report stating that healthcare and social assistance workers overall had an incidence rate of 10.3(out of 10,000 full-time workers) for injuries resulting from assaults and violent acts by another person. The rate for nursing and personal care facility workers was 21.8. A major population-based study obtained data from nurses and showed a rate of physical assaults at 13.2 per 100 nurses per year and a rate of 38.8 per 100 nurses per year for non-physical violent events (threat, sexual harassment, verbal abuse).
(CDC, 2020a)
In the United States, workplace violence increased by 23 percent to become the second most common fatal event in 2016 (Al-Qadi, 2021). Approximately 25 percent of nurses report being physically assaulted by a patient or family member, over 50 percent report exposure to verbal abuse or bullying, and it is estimated that workplace violence causes 17.2 percent of nurses to leave their job every year (Al-Qadi, 2021).

The Challenge of Underreporting
As attention to the issue of workplace violence has increased due to alarming statistics, many experts believe they represent only a small portion and that most violent events go unreported. There are several reasons why nurses and other healthcare staff may forego reporting violent incidents. A persistent perception within healthcare is that workplace violence is "part of the job." There is a concern that violence happens so frequently that it is time-consuming to report every event, and in addition to, a lack of response when time is taken to report. Many hospitals have an overly complex reporting procedure that creates a disincentive for reporting. Some fear that reporting will reflect poorly on the nurse and may result in victim-blaming. It is also common for healthcare staff to believe that some patients cannot be held accountable for their violent actions. And lastly, there are poor or non-existent institutional policies, procedures, staff training, or support in relation to violent incident reports.
(CDC, 2020b)

The Impact of Workplace Violence
Healthcare workers who have experienced workplace violence on a frequent basis have lower job satisfaction, and higher job burnout and some even leave their job, which contributes to worker shortages in hospitals. Workplace violence results in an unhealthy work environment, which may lead to a decline in work enthusiasm and patient empathy, resulting in a lack of trust between staff and patients. Along with physical and psychological injuries resulting from workplace violence, patient safety is negatively affected. Healthcare workers who experience patient violence report lower perceptions of patient safety. Overall significant impacts include reduced mental health and work ethic of healthcare workers, lower perceptions of patient safety creating a lack of quality patient care, and higher turnover rates adding to the nursing shortage.
(Duan et al., 2019)

Factors that Lead to Violence
A mixed-methods study composed of 231 nurses and 447 physicians from a university tertiary hospital yielded interesting results. Of 4,047 statements obtained by the staff regarding factors contributing to the eruptions of violence, 39 percent referred to staff behavior, 26 percent to patient/visitor behavior, 17 percent to organizational conditions, and 10 percent to waiting times (Shafran-Tikva et al., 2017). In addition, 35 percent of the staff respondents reported that their own behavior contributed to the creation of the most severe violent episodes in which they were involved, and 48 percent stated that staff behavior contributed to violent episodes (Shafran-Tikva et al., 2017). Half of the reasons stated by the nurses and physicians for violent events were related to patient dissatisfaction with the quality of service, the degree of staff professionalism, or an unacceptable comment of a staff member. The results also pointed to a lack of understanding of the hospital system on the patients' part, poor communication between patients and providers, and expectations gaps.
Violent incidents erupt due to the constellation of multiple factors, but staff behavior plays a role in the creation of violence in hospitals. Both sides, patients and nurses, are causative factors and both have feelings of fear, frustration, loss of control, pressure, and overload after involvement in a violent episode.
Staff behavior that contributes to workplace violence can be related to work overload, long shift hours, burnout, nurse-patient ratios, emotional exhaustion, and a lack of human resources (Bernardes et al., 2021).

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ANALYSIS: Nurses' Current Roles and Participation 

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ANALYSIS: Nurses' Current Roles and Participation 

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Nurses are speaking out against workplace violence and asking for support from the government and hospitals. The nation's largest union of nurses, National Nurses United, announced support for the Workplace Violence Prevention for Health Care and Social Service Workers Act in 2021.

"We applaud Representative Courtney for introducing this critical legislation that will save so many lives. Studies have shown that having a plan in place to stop healthcare workplace violence before it happens reduces incidents of violence -and yet, there is no federal requirement for healthcare employers to have a prevention plan... We urge Congress to swiftly pass Rep. Courtney's bill." - NNU Executive Director Bonnie Castillo, RN
(National Nurses United, 2021)

More recently, in 2022 on February 24th, Maine Medical Center registered nurses spoke publicly about the violence they experience in the workplace, and how their facilities management can better protect them.

"We are here today to be very, very clear: Main Medical Center has not been keeping us safe. And when we are not safe, then our patients are not safe. Maine Medical Center says it is taking steps to resolve these issues, but violent attacks on nurses are increasing, not decreasing." - Lucy Dawson, an RN in Maine Medical Center's Emergency Room
(National Nurses United, 2022)

Days later, registered nurse Lucy Dawson reported, "It took a long time. But I'm happy to report that we did get some movement from Main Med yesterday on our key staffing demands. Still more needs to be done immediately so that nurses are safe at work."
(National Nurses United, 2022)

Nurses are doing what they can to raise awareness of their unsafe working conditions. They are demanding greater protection and pushing for their voices to be heard. When nurses come together, they are able to achieve attention from the government and hospitals to do better and take the steps necessary to make the profession of nursing safe.

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(National Nurses United, 2016)

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Workplace violence impacts nurses directly. Nurses have a unique insight into patients' behaviors and the hospital safety policy, thus making them important advocates for this issue. Nurses can and should become involved in the fight against workplace violence. Although this is a complex issue that requires support and change from multiple factors, there are still some things nurses can do:

Participate in workplace violence educational training programs

Stay up to date on the hospital's safety policy and procedures

Be attuned to your own responses and be aware of patient behaviors

Report violent events

Speak up if you experience a violent event or witness violence against someone else

Press chargers if you are assaulted

Support co-workers who experience violence

Join and/or support nursing associations and healthcare agencies that provide useful information on the prevention of healthcare workplace violence

(Jones, 2021)
Nurses' involvement is essential to the success of reducing workplace violence. By implementing the strategies above nurses can help to improve their safety and the safety of their patients. By being educated, aware, and prepared nurses can influence the events leading up to violence and possibly prevent violent incidents before they occur.

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This issue is not something new, OSHA goes over statistics and costly effects of workplace violence in healthcare from 2013.

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ANALYSIS: Barriers to Nurse's Involvement

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ANALYSIS: Barriers to Nurse's Involvement

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One challenge for nurses' involvement in this issue is that there is a lack of effective violence prevention programs within hospitals. Research states that effective workplace violence prevention programs are essential, yet proper implementation of these programs is a challenge. Barriers to effective workplace violence prevention programs include the following: profit-driven management models, lack of management accountability, a focus on customer service, a lack of action despite reports, varying perceptions of violence, and weak social service and law enforcement approaches to mentally ill patients. These challenges are both within the program itself and related to broader industry and societal issues.
(Blando et al., 2015)

Nurses may also limit their participation in reporting violent events. The lack of reporting is a serious barrier to effective research and regulatory or legal actions. A few reasons for this barrier include that nurses are not aware of how and what types of violence to report and believe that the hospital pays greater attention to patient satisfaction rather than staff. It is highly reported that there is a lack of management support after reporting violent events. Another potential cause is a lack of a reporting system within the hospital.
(Song et al., 2021)

Nurses are having to fight against the business aspect of healthcare. In 2021, the U.S. House of Representatives passed H.R. 1195, the Workplace Violence Prevention for Health Care and Social Workers Act. It is now in review by the Senate Committee on Health, Education, Labor, and Pensions. The AACN joined with the Nursing Community Coalition to support this House bill. However, the American Hospital Association opposes this bill stating that new OSHA standards are unwarranted because hospitals have already implemented policies and programs to address workplace violence. They believe that the bill's mandates would cost hospitals too much money and place a financial strain on hospitals in rural communities.
(Jones, 2021)

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1.  Eliminate the "normalization" of Workplace Violence Against Nurses
Violence should never be allowed or ignored in healthcare. Nurses must not fall into the trap of accepting a patient's behavior because they associate it with the patient's disease or believe it is "a part of the job." Nurses should instill a culture of zero tolerance toward workplace violence and break down the notion that violence is expected or acceptable. All nurses should encourage each other to speak out against violence and report any type of abuse.

2. Learn and Implement Workplace Violence Prevention Strategies
Education is primary prevention and it can be used to stop violence before it occurs. Education also reinforces that violence is not an acceptable part of nursing. Nurses should actively participate in educational workplace violence courses and training. It can provide nurses with the proper knowledge and practical skills to prevent and manage incidents of violence.
(ANA, 2019)

3. Support Fellow Nurses
Workplace violence can result in negative long-term effects for those involved. With nurses already facing many challenges in their profession, it is important to provide support for those dealing with physical and psychological damage from violence. Nurses can also empower each other to demand improvement on the safety policies from hospitals and federal and state legislation.
(ANA, 2019)

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Two Curricular Concepts:

1. Nurse Autonomy
Autonomy in nursing is a circular concept I learned at SCOHS. From the beginning of the program, I was taught how to critically think and take actions related to patient care. And that is exactly what nurse autonomy is. It is the idea that nurses should have control over their practice and the ability to make decisions based on their expertise. It gives the nurse the authority to make judgments about patient care and if something directly impacts the nurse, they have a say in it.

This concept helps me to be prepared for a future leadership role in nursing because it gives me the ability as a future nurse to provide input and make decisions related to my practice. This includes departmental and organizational policies related to nursing care as well as the delivery of direct patient care. I can use my autonomy as a nurse to make positive changes in my practice and influence others to take action against issues in nursing.

2. Healthy Coping Mechanisms
Another concept I learned from SCOHS is coping techniques. A few healthy coping techniques I learned include meditation, journaling, exercise, and seeking support. Healthy coping skills are ways to deal with difficult situations and help those to become more resilient. They can help to manage painful and difficult emotions that many nurses endure in the profession.

In a future leadership role, I can assume that stress and difficult situations will arise. During those times, I can use the healthy coping mechanisms I learned from SCOHS to deal with added stress.