News & Events

Violence in Nursing

Workplace violence against hospital nurses is so common, many healthcare practitioners don’t bother to file reports. But that attitude is changing. HR leaders of healthcare facilities should increase training for nurses — to equip them to deal with potentially volatile situation — as well as enhance reporting and response mechanisms, experts say.

By Marlene A. Prost

When we think of a hazardous occupation, jobs like construction and fire fighting are at the top of the list. But when it comes to daily assaults, few professions can rival nursing.

For years, nurses have been punched and threatened by patients — from intoxicated ER patients to geriatric patients with dementia. They’ve accepted the abuse as part of the job and rationalized that, as long as they didn’t take time off, management wouldn’t care.

But that is changing. Today, nursing and hospital associations are fighting workplace violence by improving security, encouraging incident reports and fighting to strengthen state laws to prevent violence and punish offenders.

The numbers alone are staggering. Last month, a survey in Western Australia reported that slightly more than half (52 percent) of 113 registered nurses in one Australian hospital were physically assaulted in the past year by patients or patients’ families or friends. About seven in 10 (69 percent) were threatened and nearly all (92 percent) were verbally abused.

Workplace violence is a growing problem for U.S. nurses as well, says Nancy Hughes, a registered nurse and director of the Center for Occupational and Environmental Health at the American Nurses Association in Silver Spring, Md.

Healthcare workers accounted for 45 percent of all reported non-fatal assaults resulting in lost work, according to a 2005 report by the U.S. Bureau of Labor Statistics. And in 2006, the Massachusetts Nurses Association reported that half of 172 nurses surveyed had been punched at least once in the past two years, while 44 percent reported frequent verbal threats and abuse.

Not surprisingly, the biggest risks occur in emergency rooms and psychiatric units, although healthcare workers in nursing homes are often subject to abuse by geriatric residents with dementia.

"We’ve become a more violent society," says Christine Pontus, a registered nurse and associate director for Health and Safety at the Massachusetts Nurses Association. "We’re the front line. … Nurses are operating in facilities where the doors are open 24/7. Police are bringing in a spectrum of human behavior that’s not experienced in other jobs."

Kathleen McPhaul, a registered nurse at the University of Maryland School of Nursing in Baltimore, says "there is also evidence that the long wait for service, the frustration, hearing bad [medical] news, can set somebody off."

With mental-health facilities cutting beds and releasing patients to the community, some patients who come to the hospital are "sicker, more violent and decompensating," she says.

However, nurses today are less willing to tolerate abuse, says Karen Nelson, a registered nurse and senior vice president for clinical affairs at the Massachusetts Hospital Association.

Years ago, when she was a staff nurse, "nurses just had to accept … the slapping and spitting," she says. "The culture has changed to acknowledge that staff has rights, too. … Hospitals no longer accept that assault and battery by a patient is acceptable."

Improving the Environment

There is no federal standard requiring workplaces to protect nurses against violence, according to the American Nursing Association, but The Joint Commission — which accredits hospitals — does require that hospitals have a code of conduct to define disruptive behavior and implement a process to manage disruptive behavior.

Hospitals across the country are assessing risk areas and improving security, using guidelines from The Joint Commission, the Occupational Safety and Health Administration and the National Institute for Occupational Safety and Health, experts say.

Basic measures include installing metal detectors and panic buttons, setting up monitors, adding cameras and lighting in hallways, controlling access to interior areas, enclosing nurses’ stations, designing the triage area to minimize risk of assault, improving security response time and offering security escorts.

Training Nurses to Manage Behavior

Like police negotiators, nurses are being trained to defuse volatile situations verbally. That’s important in the era of patients’ rights, when staff no longer routinely use physical or chemical restraints to control patients.

"One thing we find in this country [is that] new, untrained nurses are often the victims. They don’t know how to recognize escalation. They don’t know how to defuse it," says Hughes.

Five years ago, administrators at Signature Healthcare Brockton Hospital, an urban hospital south of Boston, noticed an increase in patients with substance-abuse and mental-health issues, "who were out of control and required restraints," says Kim Walsh, a registered nurse and vice president of patient services.

The hospital, which has a locked psychiatric unit, hired a nurse with prior experience with the prison system specifically to train staff to control high-risk situations. They also created response teams to manage volatile patients, she says.

Encouraging Reporting

Nurses may confide in researchers, but they are more reluctant to tell their supervisors if they’ve been attacked by patients, experts say.

Only half of the Australian nurses who had been assaulted mentioned the incidents to senior staff or co-workers. Only 16 percent filed an official report. Thirty percent said they didn’t make a report because such occurrences are not unexpected.

"A lot of nurses feel being assaulted verbally and physically is part of the job, which is unfortunate. They don’t see it as a reportable incident. It’s more paperwork. They’re there to deal with the patient," says Elise Geig, director of health policy for the Ohio Nurses Association.

Geig says some nurses speculate that an "informal" incident report "sometimes disappears because, to be honest, it affects liability."

At worst, nurses fear they may be blamed.

"Some hospitals hold the nurse responsible. … Through their tone, they hold them responsible for the action. ‘[What did you] do to provoke it?’" says Pontus of the Massachusetts group.

Facilities need a mechanism for reporting agitated patients before they act out, Pontus says. "That’s where the gap is. We’re not recognizing the small stuff before the real stuff happens."

OSHA requires that every needle prick be reported, but when it comes to abuse, nurses are forced to make a judgment call.

"HR should encourage nurses to report any incidents, as long as they are going to do something about it," MacPhaul says. "The policies have to be created to define the incident, be specific about the reported behavior, and what the facility will do."

Hughes of the American Nurses Association says her organization encourages nurses to report all incidents. "You can always go and report, even to HR. The employer has the responsibility to provide [a safe workplace]."

"Certainly hospitals all have reporting for incidents and accidents," says Nelson of the Massachusetts Hospital Association.

She advises HR to use orientation sessions to inform nurses of their rights and reporting avenues. "If a manager learns of an incident where a staff member was harmed, you take lessons learned and make sure policies and practices are working."

Supporting Legislation

Nursing associations are lobbying for state laws aimed at strengthening criminal penalties and requiring hospitals to take more precautions.

For example, H.B. 450 was introduced in Ohio in February to make workplace assault against a nurse equivalent to assault on school employees, police, fire and emergency medical workers — a felony with a mandatory 12-month sentence. Eight other states have enacted such laws.

In Massachusetts, the nursing association is rallying around several bills, including S.B. 988, which would require hospitals to develop a comprehensive workplace-violence-prevention program. Such bills have been signed into law in eight states.

However, the hospital association maintains that the bill duplicates practices that already exist under OSHA and The Joint Commission.

March 4, 2010

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