When Workplace Violence Becomes a Public Health Issue

Violence directed at an employee occurs more frequently in healthcare settings than in nearly any other type of workplace. Nurses, nursing aides, and home health workers are most likely to become victims of healthcare workplace violence—to the extent that some experts now suggest this type of violence is a serious public health issue, rather than just another occupational hazard.

The area of greatest concern is what the National Institute for Occupational Safety and Health (NIOSH) classifies as “Type II” workplace violence. This type does not result from a criminal action like a robbery, but rather occurs when an “individual has a relationship with the business and becomes violent while receiving services.” In other words, it is violence initiated by a patient or his family member, which may take the form of a physical assault, threat, or verbal abuse. The Bureau of Labor Statistics reports that “In 2013, 80 percent of serious violent incidents reported in healthcare settings were caused by interactions with patients.” (This study reported only on violence that resulted in injuries severe enough to cause the worker to miss work.)

OSHA has identified some general factors that may increase the risk of workplace violence against nurses and other healthcare professionals:

  • A high number of patients who have psychiatric problems or are under the influence of drugs and alcohol—this applies to many emergency departments.
  • Neighborhoods with high crime rates and/or a prevalence of firearms.
  • Understaffing, which can lead to nurses working alone.
  • Conditions like crowded waiting rooms and long wait times that create frustration for patients and their family members.
  • Environmental design factors, like poor lighting in hallways or parking lots, or other design elements that limit sight distance or block escape routes.
  •  Inadequate security staff or emergency communication methods.
  • The lack of workplace policies that limit the risk of violence or train staff to either de-escalate, avoid, or remove themselves from volatile situations.
  • The perception that violence is unavoidable in areas like the emergency department and that reporting incidents will have no benefit.

OSHA itself does not require employers of any kind to create violence prevention programs. Yet some states have legislated this requirement, and many have criminalized assaults on first responders, including nurses. The ANA has created a model bill that states can adapt for their own use, with language that requires healthcare facilities to actively create violence prevention programs. The programs must include a written prevention plan that identifies risks that are specific to the facility, as well as methods for mitigating these risks. At the very least, state laws like this ensure that hospitals recognize workplace violence against nurses, rather than brushing the issue aside. Yet, according to the ANA, violence prevention programs should also provide:

  • Training for nurses on how to deal with or avoid situations that might escalate into violence.
  • A clear system in place for dealing with verbal threats and abuse before it turns into a physical assault.
  • Emergency communication plans and policies that govern what type of incidents should require mandatory summoning of security personnel.
  • Security guards in key areas, like the emergency department or psychiatric unit.
  • Adequate lighting both inside and outside the facility.
  • Alerts in the patient record, indicating a previous history of violence or abuse.
  • Workplace design and staffing procedures that don’t isolate individual nurses with patients.
  • A systematic procedure for reporting and investigating instances of abuse, and measuring progress in deterring violent encounters.

Unfortunately, at the present time, nurses are largely on their own to manage uncomfortable situations. Practice situational awareness at all times, particularly in high-risk areas, and avoid being alone with high-risk patients. Consider taking a continuing education course in de-escalating conflict. Always observe patients and visitors for verbal, situational, or body-language clues that indicate violence may be imminent. If you can’t de-escalate, remove yourself from the situation.

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