Status of Research on Violence Against Nurses

This section describes the status of research efforts related to violence against nurses, including sources of data and research, and efforts to develop standardized definitions of workplace violence.

Sources of Data and Research

One of the major challenges in documenting the crisis of violence affecting the nurse workforce is the absence of systematic and coordinated data collection procedures and scant research on these issues.  Problems with the availability of data and research include few data sources to determine the magnitude of the problem and variations in definitions, data sources, and methods used in research.  Fragmented and inconsistent funding for research, educational program development and testing add additional layers of complexity.  Finally, issues exist with curricular evaluation on preventing violence in the nursing workplace.

Because information on this important topic is limited, it must be collected from numerous sources including web sites, organizations, and government agencies.  While it is important to have uniform categories and definitions for violence in the health care setting, there are no standard reporting definitions or mechanisms for documenting violence in the health care workplace that would facilitate determination of the scope and prevalence of the problem (Gershon, 2001). 

There are insufficient health care violence-specific measurement and reporting mechanisms in place for compiling reliable data on violent injuries to nursing staff (Love & Morrison, 2003).  These authors indicated that among the policy recommendations of the American Academy of Nursing Expert Panel on Violence is the development of a national database using consistent definitions of injuries and violent events so that the true extent of the problem in health care and educational settings can be measured reliably.  They added that until pressure is brought to bear from outside regulatory agencies such as OSHA and the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), hospitals must rely on themselves for identifying and managing violence toward health care staff.  While OSHA has published workplace prevention guidelines for health care facilities and recommends a zero tolerance level for violence, Love and Morrison (2003) recommend adopting standards instead of guidelines.

There is an absence of systematic national data collection on workplace assaults, as well as scarce data evaluating violence prevention strategies (McPhaul & Lipscomb, 2004).  Methodological problems such as reporting overall prevalence rates as averages obscure the extremely high levels of aggression experienced in some departments and by specific staff (Winstanley & Whittington, 2004). 

The NACNEP recommends collecting and analyzing data on workplace violence from government agencies (e.g., Centers for Disease Control and Prevention, Occupational Safety and Health Administration, the Department of Justice), health care facilities, community-based settings, and in nursing education to assess the scope and incidence of workplace violence in Federally funded agencies and track the changes in rates of violence due to policy and procedure interventions.  They also recommend assessing the impact of workplace violence on nurse recruitment and retention; assessing management and documentation of the response to violence in the workplace; and disseminating information to health care settings in support of increased violence prevention and management programs.

Standardized Definitions of Workplace Violence

The dearth of systematic data collection procedures and sources for reporting and compiling data on violence in the nursing workforce is mirrored by the absence of a standardized definition of workplace violence.  The Institute of Medicine established some common descriptions and terms to carry out its charge.  Violence was defined broadly to include “physical, emotional, psychological, and sexual harms; the potential for harms; intentional and unintentional injury; and abuse and neglect” (Cohn, Salmon, & Stobo, 2001, p.17).  The magnitude of the problem is difficult to assess.  For example, rates vary depending on whether one includes in reporting databases severe physical injury only as compared to more minor injuries.  The report states, “the heterogeneity of definitions and evidentiary requirements makes accuracy in incidence data extremely difficult to achieve” (Cohn et al., p.22).

There is a lack of consistency in defining workplace violence across countries and at national and local levels, although a broad rather than limited definition of violence is typically used (Wiskow, 2002).  Different definitions of terms like aggression and violence make it difficult to assess changes in rates over time or across studies (Winstanley & Whittington, 2004).  “Social and cultural changes are likely to contribute to the evolution of definitions of aggression necessitating some adjustment in research definitions, thus making the accuracy and detail of reporting of particular importance” (Winstanley & Whittington, 2004, p.9).  Furthermore, terms that are employed can be interpreted differently by different parties. 

The NACNEP recommends developing and adopting a standard definition of workplace violence and disseminating information on available resources and best-practices for violence prevention and management protocols in health care settings.

There is little consensus on how to rank the degree of violence severity.  This is in part due to many nurses accepting violence as inevitable in the health care workplace (Anderson, 2001).  A broad spectrum of behaviors is included among those considered to be violent, threatening, or intimidating.  Waddington, Badger, and Bull (2005) interviewed 54 police officers and 62 health care professionals and social workers who had experienced episodes of violence in the workplace and found that there were varied meanings and interpretations ascribed to the term “violence.”  Violence can range from physical assault to attacks directed at property to non-physical aggression including verbal aggression and threats.  An inclusive definition of violence can be considered to respect the diversity of experience and the subjective nature of violence, but a broad definition may not be useful in specific applications.  The authors proposed a taxonomy of interpersonal harm that considers and differentiates factors such as the relationship between the parties involved, whether or not the situation is one of conflict, the duration and intensity of the incident(s), the target of the attack, whether or not the harm was deliberate, whether harm was realized, and whether there were legitimate grounds for complaint.

The Centers for Disease Control and Prevention’s (CDC) National Institute of Occupational Safety and Health (NIOSH) defines workplace violence as “violent acts (including physical assaults and threats of assaults) directed toward persons at work or on duty” (National Institute of Occupational Safety and Health, 2002, p.1).  Violence is defined by the American Federation of State, County and Municipal Employees (AFSCME) as “any act of aggression that causes physical or emotional harm, such as physical assault, rape, verbal abuse, threats (including bomb scares), and even sexual harassment” (American Federation of State, County and Municipal Employees, 1998).  While almost one million people become victims of violent crimes each year at work or on duty, many incidents of workplace violence are not reported.