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Workplace Violence in Nursing

Katherine L. Stear

Graduate Nursing Program, Youngstown State University

NRSE: 6900 Healthcare Issues and Trends

Dr. Valerie O’Dell

September 29, 2021

Abstract

The healthcare industry remains one of the leading industries to experience workplace violence.

Workplace violence leads to psychological and/or physical harm to workers, leading to

decreased job satisfaction and performance. Incidences greatly contribute to the ever-expanding

nursing shortage. Patient care is diminished leading to decreased patient satisfaction. Hospital

reimbursements are affected, and a growing cost related to prevention and reaction to workplace

violence is straining organizations. Prevention measures and employee training related to

workplace violence can help minimize the negative implications and create a better environment

for all.

Keywords: nursing, workplace violence, implications, prevention, risk treatment, de-

escalation, verbal judo

Workplace Violence in Nursing

Workplace violence is an unfortunate risk in most, if not all, professions. However, this

risk can be significantly greater for nurses. According to multiple researchers, the healthcare

industry has one of the highest incidences of workplace violence, with the most common forms

being patient-to-nurse violence and nurse-to-nurse violence (Demming & O’Neil, 2020; Nevels

et al., 2021). Workplace violence is on the rise. Healthcare settings accounted for 75% of the

incidences throughout 2011-2013 (Nevels et al., 2020). A lack of understanding of what exactly

constitutes workplace violence or the lack of support and intervention by organizations may lead

to under-reporting which inhibits correction and prevention of future incidences. If we are unable

to determine incidences that lead to workplace violence, there are negative implications for the

profession. According to the World Health Organization, workplace violence is “the intentional

use of physical force or power, threatened or actual, against oneself, another person, or against a

group or community, that either result in or has a high likelihood of resulting in injury, death,

psychological harm, maldevelopment or deprivation” (Al-Qadi, 2021, para 5). Nurses are at risk

of workplace violence every day and can experience multiple episodes of violence in a single

day. With a clear definition, we can investigate past instances of workplace violence to identify

root causes, allowing us to determine interventions to recognize and prevent, or lessen the

severity of, future incidences.

Historical Aspects

Patient-to-Nurse Violence

Nursing staff spends a considerable time with the public. As the frontline interface for

patients and families, we are at increased risk of bearing the brunt of their frustrations and in turn

violence (Busnello et al., 2021). Patients are responsible for 69-80% of violence (Busnello et al.,
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2021 & Nevels et al., 2020). A study over 12 months revealed nearly 80% of the participants

experienced workplace violence where 75.7% of violence was verbal aggression (shouting,

swearing, and/or cursing), 4.1% racial discrimination, and 2.3% physical aggression, most

commonly pushing and/or hitting (Busnello et al., 2021). Those working with mental health

patients, drug dependency units, or those providing life-saving care are at the highest risk of

exposure (Al-Qadi, 2020 & Nevels et al., 2020). Mental health and drug dependent patients may

experience hallucinations or delusions that increase their risk of becoming violent. Drug

dependency can lead the person to commit violent acts to satisfy their addiction. Working in

emergency departments or intensive care units where the risk of patient death is greater can lead

to increased aggression from family members. Lack of communication with family members can

lead to lack of understanding of the patient’s condition or perceived notion that not enough is

being done for their loved one. Fear in the family member can evoke verbal or even physical

violence or aggression.

Nurse-to-Nurse Violence

It has been coined that “nurses eat their young.” Perpetrators of nurse-to-nurse violence

(also known as horizontal violence) are often full-time female workers (Houston, 2020). Some

theorize the root cause of horizontal violence extends from oppression by male dominance and

this is an attempt for the individual to assert dominance among those they feel are less powerful

than themselves (Houston, 2020). Incivility may be the result of the perpetrators desire to control

or isolate a perceived threat in a co-worker. Changes in organizations, such as increased use of

technology, may lead older nurses to be fearful of appearing inadequate if they are unable to

master new technology. An increase in educational requirements, with a move towards the

standardization of the baccalaureate nurse, may incite feelings of fear in the diploma nurse that
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she could be replaced by a younger, inexperienced nurse. These perceived threats of job

insecurity may be the cause of nurses to lash out to diminish the abilities of another as well as

maintain their prevalence (Houston, 2020).

Barriers to Reporting

Although healthcare workers are more likely to experience workplace violence, many

incidences are not reported for various reasons. Lack of intervention from the organization in

response to workplace violence claims with lack of policies providing justice to claims, nurses’

belief that violence comes with the job, empathy for patients, fear of humiliation, or pride all

lead to underreporting of workplace violence (Al-Qadi, 2021).

If an employee has submitted a claim for workplace violence and the organization failed

to recognize or support the employee, the employee is likely to not report additional claims as

reporting systems are often time-consuming and there is no reward.

Lack of training and education on workplace violence may prevent nurses from

recognizing an incident and taking steps to reduce the risk or severity. Risk-reduction measures

are commonly an afterthought and only provided after the nurse has experienced an assault

(Nevels et al., 2020).

Nurses often empathize with instances of workplace violence when patients are confused,

and they feel the patient would not have used physical aggression if they were in their right state

of mind. It is common for demented or otherwise confused or disoriented patients to believe they

are being attacked or held against their will and the fight response is activated. Even if patients

are in their right state of mind, nurses often shrug off verbal aggression as they understand the

patient’s frustration and feel they would be just as upset if they were in the patient’s situation.
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Cultural norms may reduce the perceivability of workplace violence. Most of the nursing

workforce is women. Women are accustomed to dealing with sexual harassment in our culture

and may lead to underreporting as they are conditioned to this behavior. Instances of horizontal

violence may lead to underreporting as the nurse is embarrassed to go to management with

claims of bullying. Once again, our culture outside of the workplace has conditioned us to accept

a form of violence as it is common throughout our lives. Acts of racial discrimination are also

underreported as those individuals are exposed to racial discrimination daily in and out of the

workplace and history has proven that reporting such discrimination does not lead to any

resolution or any satisfactory results. Our culture may be likely to humiliate the individual

reporting victimization rather than to take steps to correct the incident.

Workplace violence incidences may be diminished as nurses do not perceive any harm

has been done because they feel as if they can handle the psychological aspect and no physical

harm has been inflicted (Al-Qadi, 2021). Nurses may feel that reporting instances of workplace

violence will lead to them being viewed as incompetent and fear loss of employment (Nevels et

al., 2020). Some are fearful that making claims will lead the institution to be apprehensive of the

individual filing lawsuits and, to prevent this, will terminate the employee.

Patient satisfaction may be perceived as more important than employee satisfaction with

the move towards hospital reimbursements and federal funding linked to patient satisfaction

scores. While the intention of the Hospital Consumer Assessment of Healthcare Providers and

Systems (HCAHPS) was to ensure accountability of institutions, but many nurses have reported

their lack of reporting workplace violence was due to the institution valuing these scores more

greatly than their safety or wellbeing (Nevels et al., 2020).

Implications to Nursing
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Impact on the Individual Nurse

Nurses can be greatly impacted by workplace violence. The second most common fatal

event in the United States is due to workplace violence (Al-Qadi, 2021). Lasting psychological

and physical harm has led to more than 50% of healthcare workers using medications to treat

depression or anxiety and even hypertension in response to the increased stress, anger, or loss of

sleep associated with job dissatisfaction (Busnello et al., 2021). Medications taken by healthcare

workers are not necessarily prescribed medications, and some nurses turn to alcohol and

substance use to cope.

Implications to Patients

Workplace violence attributes to nursing shortages. This affects every patient, not just

those directly involved in violence, as decreased staff leads to increased workloads, diminishing

the quality of care that can be provided. When a patient or a family member is aggressive, the

nurse may feel less compelled to enter the room, or to spend less time in the room, due to fear of

repetition or escalation of violence. This could lead to negligence of the patient or lack of

recognition of patient decline.

Professional Implications

Decreased job satisfaction as related to workplace violence is responsible for 17.2% of

nurses to leave the profession (Al-Qadi, 2021). This leads to increased turnover as well as a

decreased desire for recruitment to the profession. Workplace violence is expanding the nursing

shortage leading to a lack of expertise, decrease in the quality of care, and increased

organizational costs (Al-Qadi, 2021).

Organizational Implications
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Organizations have a moral obligation to their employees to prevent them from harm, but

they also face incredible costs related to prevention and response to workplace violence.

Workplace violence costs businesses more than $130 billion a year, with hospitals attributing

$2.7 billion in prevention and response (Nevels et al., 2020) and over $400 million on insurance

and medical care (Al-Qadi, 2021).

Proposal to Resolve

Occupational Safety and Health Administration (OSHA) is developing a plan to

standardize rules preventing workplace violence (Nevels et al., 2020). These include risk

treatment interventions, workplace prevention programs, and communication and training for

employees.

Risk treatment interventions include use of personal alarms, increase of security

presence, or use of the buddy system in high-risk visits. If situations escalate, the nurse needs

assistance immediately to prevent or reduce physical harm.

Workplace prevention programs would institute a zero-tolerance policy that promises to

prosecute violators to the full extent of the law (Demming & O’Neil, 2020). Identifying patients

or family members as aggressors can allow the nurse to prepare herself for a situation and be

defensive rather than reactive. The use of lethal weapons occurs more at night as there may be

increased wait times due to decreased staff (Al-Qadi, 2021). To reduce the risk of injury, metal

detection at entry points and limiting public access as well as visitation during night hours can be

established. The ability to lockdown entry points and units when there is an armed assailant in

the building is paramount to protect staff members and patients.

Committees dedicated to investigating events and determining the cause and identifying

trends would help members to understand what led to an event and how to prevent future events
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(Demming & O’Neil, 2020). These committees could also be responsible for following up with

the employing and providing needed support. Support of the organization leads to an increase in

reporting of incidences, which is the most important action after an incident (Demming &

O’Neil, 2020).

Education for employees would include defining workplace violence, how to identify it

as well as factors leading to it, how to respond to it, and how to report it. By identifying factors

leading to violence, nurses can take steps to prevent the situation from escalating and prevent the

violence. If the nurse is unable to prevent violence, she should be trained in de-escalation as well

as self-defense if the violence becomes physical. George Thompson developed a technique he

coined “verbal judo” that calms patients and reduces conflict (Nevels et al., 2020). This

technique would be invaluable education to staff members to assist in de-escalation and

prevention of violence.

Conclusion

Compared to other industries, healthcare remains one of the top industries experiencing

injuries related to workplace violence (Nevels et al., 2020). Psychological and physical harm can

have long-term negative effects on the individual as well as the organization and the profession.

There are serious implications at every level. It is nearly impossible to eradicate workplace

violence. However, with the implementation of standardized workplace violation prevention

measures, we can greatly reduce the risks for nursing leading to improved outcomes for

employees, patients and their families, the organization, and the profession.
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References

Al-Qadi, M. M. (2021). Workplace violence in nursing: A concept analysis. Journal of

Occupational Health, 63(1), 1-11. DOI: 10.1002/1348-9585.12226

Busnello, G. F., de Lima Trinidade, L., Pai, D. D., Colome Beck, C. L., & Pimenta Lopes

Riberioa, O. G. (2021). Types of workplace violence in nursing in the family health

strategy. Anna Nery School of Nursing, 25(4), 1-11. DOI: 10.1590/2177-9465-EAN-

2020-0427

Demming, J. M. & O’Neil, L. (2020). Key components of an effective workplace violence

program. Journal of Healthcare Protection Management, 37(2), 94-98.

Huston, C. J. (2020). Professional issues in nursing: Challenges and opportunities (5th ed.).

Wolters Kluwer.

Nevels, M., Tinker, W., Zey, J. N., & Smith, T. (2020). Who is protecting healthcare

professionals? Workplace violence & the occupational risk of providing care.

Professional Safety Journal, 65(7), 39-43.