Violence Against Nurses

Introduction

Violence against nurses is a complex and persistent occupational hazard facing the nursing profession. This violence can take the form of intimidation, harassment, stalking, beatings, stabbings, shootings, and other forms of assault. Nurses are among the most assaulted workers in the American workforce. Psychological consequences resulting from violence may include fear, anxiety, sadness, depression, frustration, mistrust, and nervousness. These consequences can have a negative impact on nurse retention.

To evaluate the problem of violence against nurses and its impact, and to develop recommendations to address the problem, the National Advisory Council on Nurse Education and Practice (NACNEP) conducted a thorough literature review in 2005 focused on the problem of violence affecting the nursing workforce. Included in the review were published literature, unpublished policy statements, and guidelines and regulations from various agencies and organizations. The major topics explored were the nature of violence in the nursing workplace (including statistics, risk factors, violence directed against nurses, inter-staff violence, and violence directed at patients by nurses); violence in the nursing education environment; violence experienced by nurses outside of the workplace; and violence toward patients that is detected, reported, and addressed by nurses.

The purpose of this report is to highlight the NACNEP’s review of the problem of violence against nurses and put forward recommendations to address the problem.

Overview of the Problem

The media has provided extensive coverage of workplace murders by disgruntled former or current employees in the general workforce.  Those events, while certainly serious, are relatively rare.  Far more common are assaults, threats, stalkings, and other forms of non-fatal violence in the workplace.  Violence targeted at health care workers is of particular concern, as these workers are among the most likely in the workplace to be assaulted. 

Incidences of violence early in nurses’ careers are particularly problematic as they may lead nurses to become disillusioned with their profession.  Nurses often feel powerless to deal with a situation in which they have been victimized and, as a result, accept violence as part of the job.  Homeyer (2005) found nurses are often reprimanded or fired if they defend themselves against violence. 

As job satisfaction decreases as a result of violence, the likelihood of nurses leaving their employment increases with nurses finding different roles within the health care setting or leaving the profession entirely (Shader, Broome, Broome, West, & Nash, 2001).  The lack of support from administrators in addressing problems of violence in the workplace is a contributor to burnout and resignations of even the most seasoned veteran nurses.  This is an issue that the profession and health care industry cannot continue to ignore especially in light of the current nursing shortage. 

Statistics on Violence against Nurses

There is considerable evidence that workers in the health care sector are at greater risk of violence than workers in any other sector. The U.S. Department of Labor, Bureau of Labor Statistics (BLS) showed that 48 percent of all non-fatal injuries from occupational assaults and violent acts occurred in health care and social services settings (U.S. Department of Labor, Bureau of Labor Statistics, 2001). The BLS data also showed that while two in 10,000 employees overall in the private sector suffer injuries annually that require time off from work, rates of injuries are significantly greater for health care employees. Annually, 9.3 in 10,000 employees in the health services sector suffer injuries that require time off from work. In nursing and personal care facilities, 25 in 10,000 employees suffer such injuries – more than 10 times the overall private sector rate. This data is depicted in the chart below.

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* Incidence is defined as assault resulting in injury that requires time off from work
Source: U.S. Department of Labor, Bureau of Labor Statistics (2001).

Nurses are especially at risk as they are the most likely of all health care providers to be assaulted.  The U.S. Department of Justice, Bureau of Justice Statistics (BJS) National Crime Victimization Survey 1993-1999 showed that the health care sector led all other industry sectors in the incidence of non-fatal workplace assaults and that nurses are the most likely of health care workers to be assaulted (U.S. Department of Justice, Bureau of Justice Statistics, 2001).  According to the Department of Justice data, nurses are 57 percent more likely to be assaulted than are physicians.  Assault rates are particularly high among emergency department (ED) nurses (Roll, 2005).  In a recent survey of 125 ED nurses, intensive care unit and general floor nurses at a regional medical center, 82 percent of ED nurses had been physically assaulted at work during 2001 (May & Grubbs, 2002). 

Underreporting of Statistics

As sobering as these numbers are, they are likely understated. Nurses are reluctant to report violence that is committed against them in the workplace. One study involving nearly 8,800 nurses in 210 hospitals revealed that 70 percent of the nurses experiencing abuse had not reported that mistreatment (Duncan & Hyndman, 2001).  A survey of more than 4,700 Minnesota nurses revealed that only 69 percent of physical violence incidents were reported (Gerberich et al., 2004).  In a study by Findorff, McGovern, Wall, and Gerberich (2005), of the 923 respondents who experienced aggression from physicians, 43 percent did not report the incident to their employer.  Of those who experienced other non-physical violence at work, 60 percent did not report these events.  In this same study, when violence incidents were reported, 86 percent of the reports were oral (rather than written reports).  These findings suggest that violence incidents are significantly underreported and that those incidents that are reported may be under managed.

The causes for underreporting are numerous.  Many nurses believe that being assaulted may be viewed as poor performance on their part, or that assaults are just part of the job.  In a survey of emergency room nurses, more than half agreed with the statement, “Nurses who take legal action against a patient are in jeopardy of losing their jobs.”  In addition, 76 percent stated that their decision would be based on whether the patient was perceived as being responsible for their action (Erickson & Williams-Evans, 2000).  When nurses are assaulted in the workplace, they typically feel compelled to consider a variety of factors before taking legal action against the assaulting patient.  This may involve some accommodation because the nurses believe that assailants (e.g., psychotic patients, distraught family members) may not know what they are doing.  Erikson and Williams-Evans (2000) asserted that most nurses believe violence and assault are part of the job, and they presented evidence suggesting workplace violence has a normative effect, meaning that over time, frequent violent acts and aggression gradually become accepted as part of the workplace culture. 

In addition, nurses are often confused about what legally constitutes abuse or assault, and policies and procedures for reporting violent events are not clear (May & Grubbs, 2002).  The literature overwhelmingly suggests that nurses generally feel unsupported by management in relation to workplace violence, and this could well influence a nurse’s decision not to report unacceptable behavior (Jackson, Claire, & Mannix, 2002).  There is a belief that hospital administration may want to avoid the publicity that could accompany pressing charges against a patient (Homeyer, 2005).  This may discourage nurses from taking legal action, because they perceive management will not support them.

The NACNEP recommends eliminating institutional barriers for a safe work environment by supporting a culture of open communication and reporting among nursing staff, faculty, health care personnel, and students regarding violence in the workplace.  Furthermore, the NACNEP recommends providing clearly defined support resources such as legal and psychological services to nurses in violent situations or at risk of facing violent situations.

Types of Violence Affecting the Nursing Workforce

Violence that affects the nursing workforce comes in many forms.  The most common form is violence committed by patients in the workplace.  However, violence affecting nurses is also seen in the educational setting and outside the workplace.  

Violence in the Workplace

Forty-five percent of violence committed against nurses in health care facilities is inflicted by patients.  Nearly one-third of violent acts against nurses are committed by family members of patients, visitors, and health care providers, including physicians (Homeyer, 2005).  Typically, the assailants are males who are impaired (Gerberich et al., 2004).  The most common causes of assault by family members of patients are anger related to staff enforcement of hospital policies, the patient’s situation or condition, long wait-times, or the health care system in general (May & Grubbs, 2002).  This type of violence is most common in nursing homes, long-term care facilities, intensive care units, emergency departments, and psychiatric departments. 

While patients are the most frequent source of sexual harassment and physical assault against nurses, over half of the sexual assaults are committed by physicians (Williams, 1996).  Physicians are also a frequent source of verbal abuse (Sofield & Salmond, 2003).  In a survey of 1,000 nurses at a large hospital system, 91 percent of respondents had experienced verbal abuse in the prior month and the most frequent aggressor was a physician (Sofield & Salmond, 2003).  Farell (1999) and McMillan (1995) also found that nurse managers often used aggression toward staff nurses. 

Violence in health care facilities is fostered by a complex set of institutional and social forces that work to aggravate the problem.

Cost pressures: Cost pressures make it difficult to train staff to deal with violence in the workplace.  Not only is the cost of training expensive, but when combined with paying the salaries of other staff to cover for those in training, the overall costs can be prohibitive (Roll, 2005).

Staffing shortages: Staffing shortages have resulted in lower standards for hiring (Bradley & Moore, 2004).  Under pressure to fill vacant positions, given the nursing shortage, facilities may take shortcuts in the hiring process or adhere to lower standards for staff hired.  Nurses and other employees who have not been subjected to effective internal screening practices, including a review of prior employment records, criminal convictions, or driving records, put the institution at risk (Bradley & Moore, 2004).

Characteristics of patients: Acute care settings are under increasing financial pressures including those from growing numbers of uninsured patients, and this, combined with staffing shortages, can result in longer patient wait-times and inadequate security – both risk factors that can contribute to violence (McPhaul & Lipscomb, 2004).  Family violence is also pervasive, and nurses often encounter violent family situations that make their way into health care settings (Gerberich et al., 2005).  Furthermore, many of the patients at risk for perpetrating acts of violence are cognitively impaired at the time they enter the nursing workplace or distressed by their health problems, increasing the likelihood of their committing aggressive acts.

Poor or stressful working conditions: Substandard conditions in workplace environments, characterized by poor communication and under resourced facilities, lead to tensions that can contribute to aggression (Duxbury & Whittington, 2005).  Additional risk factors leading to violence in the workplace include working in intensive care, mental health, and emergency departments (Findorff, McGovern, Wall, Gerberich, & Alexander, 2004), most likely because of the high stress in these work sites.

Attitudes among management, nurses, and students: As described previously, an accepting attitude toward violence in the workplace is commonplace (Beech, 2001).  Often, customer service initiatives (e.g., minimizing the physical barriers between caregivers and patients, encouraging nurses to “be nice” to customers) take priority over facilities’ focus on keeping the staff safe from aggressive patients (Homeyer, 2005).

The NACNEP recommends offering violence prevention and management training in the workplace and keeping violence and security issues on the radar screen of risk managers in health care facilities. 

Violence in the Nursing Education and Training Environment

Academic environments are also vulnerable to violence.  Love and Morrison (2003) noted studies documenting increased verbal threats, harassment, intimidation, and stalking of nursing faculty by students who are experiencing academic problems or facing termination from the program.  Many schools have instituted criminal background check policies for students and faculty in efforts to address this problem (Burns, Frank-Stromborg, Teytelman, & Herren, 2004).  Tate and Moody (2005) discussed extending authority to conduct criminal background checks for nurses.  They also proposed conducting checks for students upon entry to clinical nursing courses and as a pre-requisite for graduation and application for licensure.  Typically, applicants are required to pay for criminal background checks (National Council of State Boards of Nursing, 2005).  The NACNEP recommends developing guidelines for conducting employee and student background checks on violent behavior.

Impact of Violence on Recruitment and Retention

Violence in the health care workplace is of particular concern given the importance of retention in the nursing profession.  It is strongly correlated to factors in job dissatisfaction such as powerlessness and low morale (Jackson et al., 2002).  This feeling of lack of empowerment among nurses, due directly to violence in the workplace, has often been correlated with sick leave, burnout, and poor recruitment and retention rates (Jackson et al., 2002).

Workplace aggression is the most anxiety-provoking aspect of nursing work for a significant number of nurses, and the high levels of workplace violence experienced by nurses may be a factor in the loss of experienced staff (Sourdiff, 2004).  It is often “the straw that breaks the camel’s back” that causes nurses, who often feel overworked and inadequately protected against workplace violence, to leave their jobs (McPhaul & Lipscomb, 2004). 

Effects of Non-Physical Abuse on Retention

One of the least-reported forms of violence is non-physical, though it may be more prevalent than physical violence in affecting the retention of nurses (Findorff, McGovern, & Sinclair, 2005).  In a survey of 1,000 nurses, Sofield and Salmond (2003) found that more than half of the respondents did not feel competent in responding to verbal abuse while 91 percent had experienced verbal abuse in the past month.  They also found that non-physical violence left the recipient feeling personally or professionally attacked, devalued, or humiliated.  Verbal abuse significantly impacts the workplace by decreasing morale and job satisfaction, and creating a hostile work climate (Sofield & Salmond, 2003).  Communication between nurses and physicians is one area where studies show verbal abuse may have a significantly disruptive impact on a nurse’s intention to stay at a job.  Rosenstein (2002) found that 30 percent of surveyed nurses knew of nurses who had left an organization because of disruptive communication and verbal abuse by physicians.  Sofield and Salmond (2003) found that physicians were the most frequent source of verbal abuse, followed by patients, patients’ families, peers, supervisors, and subordinates.  They found that the amount of abuse and intent-to-leave were significantly related.  The authors found that 12 percent of the nurses surveyed planned to actively look for a new job within the next year and 22 percent would consider resigning as a result of verbal abuse. 

Effects of Physical Violence on Nursing Retention

Physical abuse is more readily reported and thus better tracked than non-physical abuse.  In a recent survey by the Maryland Nurses Association, 18 percent of respondents indicated they had left a job because they feared for their safety; 15 percent of respondents indicated that at some point they wanted to leave but they hadn’t yet done so (Distasio, Hall, & Beachley, 2005).  A survey of ED employees in an urban inner city tertiary care center in Vancouver, British Columbia, showed that 68 percent reported an increased frequency of violence over time and 60 percent reported an increased severity of violence.  This included verbal abuse (75 percent) and witnessing physical threats or assaults (86 percent).  Over half (57 percent) of respondents were physically assaulted in 1996, with about half reporting impaired job performance for the rest of the shift or week, 73 percent indicating they were afraid of patients after the event, and 74 percent reporting reduced job satisfaction.  In this survey, of those no longer working in the ED, 67 percent reported they had left due to violence (Fernandes et al., 1999).  In a survey by Erikson and Williams-Evans (2000), 14 percent of the nurses surveyed had considered transferring out of their department, and 18 percent stated that they had considered leaving the nursing profession altogether because of fear of physical abuse.

Evidence indicates there is more job turnover associated with stress for younger nurses than with older nurses (Shader et al., 2001).  As a result, the impact of violence on retention of younger nurses is perhaps more significant than it is with older nurses. 

Violence can also have an impact on recruitment.  It is one of the factors that often make nurses reluctant to recommend nursing as a career choice.  Over half (53 percent) of nurses who were surveyed would not recommend the nursing profession as a career choice for their children and 23 percent would actively discourage someone close to them from entering the profession (Keough, Schlomer, & Bollenberg, 2003).