Prevention and Intervention Programs and Strategies

A large number of violence prevention and reduction interventions exist.  However, few of these have been evaluated to determine their effectiveness.  This section describes prevention and intervention strategies intended to reduce violence in the nursing workplace.

Reducing Violence in the Nursing Workplace

Education and Training

Educating nursing staff to prevent and respond to workplace violence is a common strategy intended to reduce the incidence and impact of violence.  Psychiatric facilities in particular experience a high incidence of aggressive behavior and have utilized several different approaches to their management through staff training.  In psychiatric settings, studies have shown that training staff in violence prevention and verbal and physical de-escalation not only improves provider knowledge and confidence in handling violent situations, but also reduces injuries (Lehman, Padilla, Clark, & Loucks, 1983; Infantino & Musingo, 1985, as cited in Morrison & Carney-Love, 2003).  In an assessment of several commonly used programs for managing aggressive behavior in psychiatric settings, Morrison and Carney-Love (2003) noted that these programs have progressed in recent years from being largely reliant on physical techniques of self-defense to incorporating more therapeutic principles.  The authors suggested that this move was positive and consistent with the United Kingdom’s 2002 standards for the education of managing aggressive behavior (United Kingdom Central Council for Nursing, Midwifery, and Health Visiting, 2002), but they argued that further evaluation of these programs is needed to determine their effectiveness. 

Nachreiner, Gerberich, McGovern, Church, Hansen, and Geisser (2005b) attempted to determine if violence prevention training decreased workplace violence experienced among Minnesota nurses.  While most nurses in the survey (a random sample of the states’ RNs and licensed practical nurses [LPNs]) reported receiving some training about workplace violence, the study did not find this training to be protective against workplace violence.  The study raises questions about why this finding might be occurring.  The study could not control for type or quality of the training, nor could it control for the possibility that training leads to a heightened recognition of violence and increased reporting among trained nurses.  More rigorous examination of the value of training on work-related violence would be useful in this regard.

The NACNEP recommends targeting funding to support basic and continuing education initiatives focused on evidence-based core competencies (knowledge, attitudes, skills, and behaviors) related to workplace violence and violent behaviors.  The NACNEP also supports improving basic and continuing education programs for nursing personnel including faculty, staff, and students on self-protection in violent situations and competency in violence prevention and management.

Institutional Policies

A survey of Minnesota nurses found zero-tolerance policies in effect in many work sites, and the odds of physical assault decreased among nurses working in locations with these policies (Nachreiner et al., 2005a).  In the same study, various other workplace violence prevention measures were examined for effectiveness.  These included prohibitions of specific behaviors (such as physical assault, threats, sexual harassment, or verbal abuse), assurances of confidentiality in reporting, flagging charts of repeatedly violent patients, delineating consequences for those who were violent at work, requiring violence training for staff, and training in reporting violent incidents.  The authors found that the nurses’ odds of physical assault decreased only in cases where their work settings had policies that prohibited specific types of violent behaviors.  

A survey of Minnesota nurses found zero-tolerance policies in effect in many work sites, and the odds of physical assault decreased among nurses working in locations with these policies (Nachreiner et al., 2005a). In the same study, various other workplace violence prevention measures were examined for effectiveness. These included prohibitions of specific behaviors (such as physical assault, threats, sexual harassment, or verbal abuse), assurances of confidentiality in reporting, flagging charts of repeatedly violent patients, delineating consequences for those who were violent at work, requiring violence training for staff, and training in reporting violent incidents. The authors found that the nurses’ odds of physical assault decreased only in cases where their work settings had policies that prohibited specific types of violent behaviors.

The NACNEP recommends establishing clear standards for workplace safety supported by resources for the management of violence.

Legislative Interventions

Very little legislation has been enacted specifically to protect nurses.  In many states it is not a felony to assault a nurse.  In some states, it is a felony to attack a physician but a misdemeanor to attack a nurse.  A key piece of legislation intended to provide protection for hospital workers is the Occupational Safety and Health Act of 1970, which mandates that, in addition to compliance with hazard-specific standards, all employers have a general duty to provide their employees with a workplace free from recognized hazards likely to cause death or serious physical harm (Homeyer, 2005).  OSHA, authorized by the Act, set forth guidelines to provide a safety and health program that includes violence prevention.  These guidelines are advisory only and provide supporting information.  They are voluntary and intended to help employers establish effective workplace violence prevention programs.  In some cases the employer can be cited for violation of the general duty clause if it fails to implement certain guidelines (Homeyer, 2005).  These guidelines address only the violence inflicted by patients or clients against staff.  They do not explicitly address violence inflicted by third parties; however, OSHA suggests that workplace violence policies indicate a zero-tolerance for all forms of violence from all sources.

California provides an example of a legislative intervention to prevent workplace violence.  In 1993, the California Hospital Security Act (AB508) passed which included requirements for acute care facilities to provide safety and security training to employees, conduct assessments of facility safety and security, develop and implement a security plan, and report to authorities all assault and battery acts within 72 hours of occurrence (Peek-Asa, Cubbin, & Hubbell, 2002).  Surveys of California’s emergency departments before and after implementation of AB508 found that the hospitals reported fewer violent episodes after its implementation as well as overall improvements in the departments’ security programs, but the study could not directly attribute these improvements to the legislation (Peek-Asa, Cubbin, & Hubbell, 2002).

Guidelines

Various organizations have prepared guidelines and recommendations to prevent and manage violence in the workplace.  For example:

• American Nurses Association (ANA), 2002.  Preventing workplace violence. ANA. Washington, DC.
• International Council of Nurses (ICN), 2000. Position statement: Abuse and violence against nursing personnel. ICN. Geneva, Switzerland.
• National Institute for Occupational Safety and Health (NIOSH), 2002. Violence: Occupational hazards in hospitals. NIOSH Publication number 2002-101. U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention. Washington, DC.
• Occupational Safety and Health Administration (OSHA), 2004 (revised). Guidelines for Preventing Workplace Violence for Health Care and Social Service Workers. U.S. Department of Labor, Occupational Safety and Health Administration. Washington, DC.

Strategies for Changing the Health Care Culture

The culture of violence pervades the health workplace.  This in part reflects the community at large.  But despite the calls by researchers and the public alike for a change in the culture that supports or promotes violence in the workplace, there is very little in the literature that specifies exactly how this culture should or can be changed and whether such a strategy would be effective.  Although this elusive goal has wide support, additional research is needed to develop and assess strategies that have the potential to change a culture that is so well-rooted and pervasive.

Some researchers highlight the importance of advocacy of nurses and establishment of a zero-tolerance policy to protect nurses (Henderson, 2003).  Others emphasize the impact of environmental factors such as use of coercion and an authoritarian nursing style as precursors to patient aggression (Duxbury & Whittington, 2005).  Other research points out the need for additional research and the need to better understand the culture of violence in hospitals (Duncan & Hyndman, 2001; May & Grubbs, 2002; Findorff, McGovern, & Sinclair, 2005).

Basic and Continuing Education and Training Curricula

It is difficult to identify appropriate violence-related training for nurses, and there is little published evidence of the effectiveness of the training and education programs currently in place.  Nonetheless, there is strong sentiment and general agreement among many in the profession that effective basic and continuing education and training in violence identification, prevention, and treatment are needed.  This has been the position of many policy organizations such as the American Nurses Association.

Limitations of Violence Training and Education

The lack of evidence of the effectiveness of education and training tools may be a reason why there appears to be limited violence training and education in nursing schools. In a 1999 follow-up to a 1995 national survey of baccalaureate nursing programs in the United States, little change was found in the overall nursing violence-related curriculum; the majority of schools reported no violence-related faculty development during the past four years, 68 percent did not systematically evaluate violence content, and 75 percent had not developed violence-focused student competencies (Woodtli & Breslin, 2002).  The NACNEP recommends targeting college and nursing school faculty development initiatives on violence in nursing focusing on prevention, early intervention, legal and ethical issues, and access to resources and referral systems in both educational and clinical environments.

With regard to a workplace violence curriculum, more than 40 percent of nurses responding to a survey of Minnesota nurses reported that they were trained in workplace violence (Nachreiner et al., 2005a).  But the long-held belief that violence is part of the nursing job, and that it is an inherent nursing occupational hazard, is thought to limit the extent of violence prevention training and education in the nursing workforce (Pieri, 2004).  In addition, the incidence of workplace violence prevention and management training may be low because the effectiveness of the training tools that are available is not known (Nachreiner et al., 2005b).