Assaultive Behavior and Workplace Violence - 3 Contact Hours
- NIOSH Classification of Workplace Violence
- Risk Factors for Workplace Violence
- Identifying Violent Attackers
- Preventing Workplace Violence
- Occupational Safety and Health Administration Recommendations for Preventing Workplace Violence
- What Not To Do
- Putting our Knowledge to Practice
≥92% of participants will work actively to prevent workplace violence in the healthcare setting.
After completing this continuing education course, the participant will be able to meet the following objectives:
Recognize the WHO definition of workplace violence.
Define interpersonal violence.
Identify the top two causes of work-related deaths in the US.
Examine a barrier associated with reporting workplace violence as put forth by the ANA.
Identify the nursing specialty known to report the highest prevalence of workplace violence.
A pervasive cultural mindset suggests that workplace violence is an acceptable part of the job for healthcare providers, specifically nurses and nurses’ assistants, who spend the most time with patients compared with other healthcare professionals. Violence must not be normalized by governing bodies, policymakers, or healthcare workers themselves.
Definition of workplace violence
The World Health Organization (WHO) defines workplace violence as “the intentional use of power, threatened or actual, against another person or a group, in work-related circumstances, that either result in or has a high degree of likelihood of resulting in injury, death, psychological harm, mal-development, or deprivation (WHO, nd).”
The National Institute for Occupational Safety and Health (NIOSH) defines workplace violence as violent acts, including physical assaults and threats of assault, directed toward persons at work or on duty (NIOSH, 2021).
Several factors have contributed to the rising incidence of violence in our communities in general and in the healthcare community, in particular, which are outside the scope of this discussion. Nonetheless, healthcare workers are increasingly tasked with caring for patients who have caused or are at risk for causing self-harm or inflicting harm on others.
In 2018, there were 67,792 violence-related deaths in the United States (US) (CDC, 2020). Health care workers are even more at risk due to their responsibility to prevent disease and respond to medical emergencies appropriately, even when patients are violent, either self-directed violence or interpersonal violence. Interpersonal violence is defined as the use of physical force to injure others.
In 2017 the total medical costs related to violence were approximately $8.7 billion related to emergency visits, hospitalizations, and short-term and long-term care needs (Grossman & Choucair, 2019).
Clinicians have adopted screening for violent patients to prevent violent acts in the workplace to protect both patients and healthcare workers. Unfortunately, today's reality is workplace violence can occur in any work setting, especially in the clinical setting. Clinicians must anticipate and remain vigilant at all times to effectively manage and cope with aggressive patients and those with the potential to become violent.
Frequently, media outlets sensationalize every incidence of violence, and the advent of social media makes reports of violence an ever-present threat seeking to grab our attention. In the long run, this desensitizes us to violent situations that have long-lasting psychosocial consequences on society. More specifically, violence in a clinical setting can have debilitating results affecting not just the patient being violent but also the clinical staff and other patients. There are financial ramifications borne by the perpetrators of violence, the victims of violence, and the employers of these institutions or clinics where violence occurs.
According to the National Safety Council (NSC) data, in 2018, there were a total of 900,380 incidents that caused employees to request days off from work, including assault, nonfatal injuries, and illnesses. Of these, 20,790 were related to assault, both fatal and nonfatal assaults. Note that this corresponds to assault, accounting for approximately 2.3% of all incidents involving days away from work (NSC, nd).
Work-related assault ranks second place in work-related deaths after motor-vehicle crashes. Although the number of work-related deaths has decreased in recent years, the number of nonfatal injuries in the workplace has increased. In 2018, the number of fatal work-related assaults was 453 compared to 458 in 2017. At the same time, the number of nonfatal work-related injuries was 20,790 in 2018, compared to 18,400 (NSC, 2019).
The National Safety Council (NSC) currently categorizes work-related assaults into different types of events, namely:
- Threats and verbal assaults
- Rape and sexual assault
- Hitting, kicking, beating, and shoving
- Stabbing, cutting, slashing, or piercing
- Bombing and arson
On average, the median days away from work used by individuals who have experienced an assault is five days. This time away from work corresponds to an average of 1 week off from work and may be related to loss of income for the individuals involved. The average worker gets approximately two weeks of vacation (NSC, nd).
According to the United States Department of Labor Bureau of labor statistics, in 2018, the three private sector industries which had the highest distribution of nonfatal occupational injuries in the private sector were8:
- Healthcare and social assistance with 544,800 cases
- Retail trade with 401,100 cases
- Manufacturing with 395,300 cases
Note that healthcare and social assistance was ranked as the number one industry in the private sector with the highest number of nonfatal occupational injuries (SOII, 2018).
Violence Against Nurses
Of all healthcare professionals, nurses and nurse’s assistants spend the most time with patients. They are the group of healthcare professionals who most frequently experience violence. However, not all nurses experience workplace violence at the same rate since some work settings have been associated with an increased incidence of workplace violence.
A cross-sectional study by Ching-Yao et al., 2015 which sampled almost 27,000 nurses, sought to identify the prevalence of workplace violence and noted that 49.6% of the nurses had experienced at least one episode of violence in the past year. Of those, 19.1% had been exposed to physical violence, and 46.3% had experienced non-physical violence. They also looked at the prevalence of violence based on the work setting and noted that prevalence varied greatly based on the work environment. Intensive care unit (ICU) or emergency room nurses reported the highest prevalence. In fact, up to 55.5% of nurses working in the ICU or emergency setting had experienced workplace violence (Ching-Yao et al., 2015).
Another interesting finding was that nurses between the ages of 55-65 years had the lowest prevalence of workplace violence (28.3%). Overall, after adjusting for other confounders, they concluded that younger nurses were more at risk of being exposed to violent threats (Ching-Yao et al., 2015).
NIOSH Classification of Workplace Violence
Type 1: Criminal Intent
In Type 1 violence, the perpetrator has no legitimate relationship to the business or its employees and is usually committing a crime in conjunction with the violence, such as a robbery or shoplifting. For example, a hospice nurse gets robbed while walking to her car from a home visit. Note that in the home health care settings, Type I violence occurs less frequently than other types of violence (NIOSH, 2021).
Type 2: Customer or Client
Type 2 violence is the most common type of workplace violence in healthcare settings. Patients are considered clients for this course. Also, the customer or client relationship includes patient family members and visitors and can be referred to as client on worker violence. Typically, workplace violence occurs in the emergency department, mental health or psychiatric treatment settings, senior facilities, and waiting rooms. However, type 2 workplace violence is not limited to these settings (NIOSH, 2021).
Type 3: Worker-on-Worker
Type 3 violence between coworkers is also known as lateral or horizontal violence. It includes bullying and may be demonstrated as verbal and emotional abuse that is unfair and vindictive. Sometimes perpetrators of horizontal violence seek to humiliate their victims. Occasionally, the punishment they inflict on their victims may be taken too far and has resulted in homicide in some instances. Worker-on-worker violence is often directed at subordinates. Typically, supervisors or superiors inflict horizontal violence on people under their charge. For example, a nurse manager being violent to floor nurses or an attending physician being violent to resident physicians. However, worker-on-worker or peer-to-peer violence is also common in healthcare settings (NIOSH, 2021).
Type 4: Personal Relationships
In Type 4 violence, the perpetrator has a relationship with the healthcare worker outside of work that spills over to the work environment. For example, the boyfriend of a nurse’s aide follows her to work after a fight. Other examples of violence include a husband calling his wife’s job to threaten her or a nurse’s roommate calling her job to threaten her and make threats against her coworkers and potentially her patients. Note that coworkers and patients can become unintended victims of violence against healthcare workers (NIOSH, 2021).
Risk Factors for Workplace Violence
The etiology of workplace violence is multifactorial, with myriad causes contributing to the root cause. These include the workplace setting, the patient’s medical history, psychiatric history, family history, the employee’s state of mind, workload requirements, and the employee’s training and experience.
According to the guidelines for Preventing Workplace Violence for Healthcare and Social Service Workers published by the Occupational Safety and Health Administration (OSHA), risk factors for workplace violence can be divided into two main categories: Patient, client or setting related risk factors and Organizational related risk factors (OSHA, nd).
Client, Patient, or Setting Related Risk Factors
- Working directly with people who have a history of violence, abuse drugs or alcohol, gang members, and relatives of patients or clients
- Transporting patients and clients
- Working alone in a facility or patients’ homes
- Poor environmental design of the workplace may block employees’ vision or interfere with their escape from a violent incident
- Poorly lit corridors, rooms, parking lots, and other areas
- Lack of means of emergency communication
- Prevalence of firearms, knives, and other weapons among patients and their families and friends
- Working in neighborhoods with high crime rates
Organizational Risk Factors
- Lack of facility policies and staff training for recognizing and managing escalating hostile and assaultive behaviors from patients, clients, visitors, or staff.
- Working when understaffed—especially during mealtimes and visiting hours.
- High worker turnover.
- Inadequate security and mental health personnel on site.
- Long waits for patients or clients and overcrowded, uncomfortable waiting rooms.
- Unrestricted movement of the public in clinics and hospitals.
- Perception that violence is tolerated and victims will not report the incident to police or press charges.
A 2014 study by Sabri et al. examined whether different racial or ethnic groups differed in their vulnerability to workplace violence. It also examined the ability to utilize the resources available in the workplace to prevent and manage workplace violence. They noted that childhood physical abuse played a role in significantly increasing the risk of workplace violence amongst all races. They also noted that amongst Asians and Whites, intimate partner violence was a significant factor in increasing the incidence of experiencing workplace violence (Sabri et al., 2015).
Also, they noted that Blacks and Asians were less knowledgeable about resources within the workplace used in preventing and addressing workplace violence. In conclusion, their study showed a significant difference in resource utilization amongst minority worker groups. This exemplifies the need for mandatory training and education programs designed for new employees and annual training and education programs targeting current employees to increase awareness of workplace violence in all populations, including minority groups (Sabri et al., 2015).
Identifying Violent Attackers
In determining whether or not an employee may become violent, one must identify warning behaviors and assess the threat of violence. To monitor behavior over time, employers must strive to create a safety culture and open communication where employees can freely report warning behaviors observed without fear of retaliation. Then, the employer must also be committed to taking appropriate interventions.
Certain behaviors have been associated with an increased risk of violence. A threatening behavior precedes most instances of violence to the victim. These threats must be taken seriously and reported to the authorities and supervisors expeditiously as appropriate. Once reported, the threats should not be ignored. They should be investigated and intervened upon as deemed appropriate. Examples of behaviors that are associated with an increased risk of violence include leakage, preparation for an attack, identifying with violent offenders, fixation on a person or subject, or a desire for retaliation
Leakage is defined as the act of revealing violent intentions to a third party, which may be intentional or unintentional. Note that leakage does not mean the person planning the violence wants to be discovered. Note that the sharing of violent plans can be veiled or specific and sometimes may be shared as a joke, threat, or while boasting. The threats may be shared verbally, through email, or posted online. Not all incidents of leakage lead to violent behavior. It must be assessed in the context of other behaviors.
Preparation for an attack, identifying with violent attackers, or fixation on a person or subject:
- Preparatory behaviors include acquiring weapons, researching subjects or locations, carrying out practice runs, or stalking potential targets. Identifying behaviors include agreeing or identifying with an agent of violence or prior perpetrators of violence.
Desire for retaliation:
- A desire for retaliation involves a perceived grievance or wrong that can become a reason for the perpetrator’s perceived or real problems. The perpetrator can then justify violence as a tool to even the score or as a form of payback. Sometimes perpetrators may feel they have no other choice except for violence because they feel cornered.
Some mental health disorders have specifically been associated with a propensity for violence, such as antisocial personality disorder, characterized by a lack of empathy or a conscience. Patients experiencing psychosis and paranoia can experience a sense of persecution, which can significantly impact their experience of loss and rejection. Triggers that can lead to violent behavior include loss of a relationship, financial stability, or death of a family member or loved one.
Preventing Workplace Violence
It is impossible to address workplace violence prevention without first addressing the challenges of identifying workplace violence.
A history of violence should be appropriately documented in the patient’s chart so that healthcare providers are immediately aware they are interacting with a patient who has demonstrated violent behavior in the past. That way, they have an opportunity to implement safety measures as deemed appropriate. A commonsense safety measure that can be easily implemented to prevent being assaulted is maintaining a safe distance from a potential aggressor, especially since violence can be perceived as more distressful when it occurs in unexpected situations.
A 2016 publication by Huang and Glenn states that all patients should be screened for violence as part of the emergency department triage process. Also, they recommend providing support for nurses who have experienced workplace violence to help them cope with the aftermath of experiencing physical violence in the workplace (Huang & Glenn, 2016).
There are several challenges involved in measuring aggression in the workplace, including the reluctance by victims to report the incident use of indirect measures to report the incidents. Huang and Glenn proposed using a handheld counter as a tool to measure aggression exposure accurately (Huang & Glenn, 2016).
Finally, the lack of information on coping and recovering from experiencing workplace violence can be a deterrent for nurses who may believe that reporting the violence is futile and is likely to be ignored by the supervisory staff (Huang & Glenn, 2016).
Occupational Safety and Health Administration Recommendations for Preventing Workplace Violence
OSHA acknowledges that healthcare and social service workers face significant risks of job-related violence, thus validating the need for guidelines that employers can use to provide a safe working environment (OSHA, nd).
OSHA acknowledges that different workplace settings pose different hazards to the employees. Consequently, they identified five different workplace settings to establish workplace safety guidelines (OSHA, nd):
- Residential treatment settings such as nursing homes or long-term care facilities
- Hospital settings or large institutional medical facilities
- Community care settings, including group homes
- Fieldwork settings including home healthcare workers or social workers
- Non-residential treatment service settings, such as neighborhood clinics
These guidelines protect healthcare, and social service workers who are protected include home healthcare workers, technicians, therapists, nurses’ aides, registered nurses, OSHA social workers, physicians, emergency care personnel, physician assistants, nurse practitioners, and other staff. They may be exposed to clients with a history of violence. When integrating these guidelines into clinical practice, it is important to listen to the workers, incorporate any good ideas, and address any concerns (OSHA, nd).
OSHA recommends reviewing records to identify patterns of assault and reviewing near misses to identify things that helped prevent the violent event.
Most of the questionnaire respondents who self-reported a violent event in the past year had not documented an incident in the electronic system (88%). However, more than 45% had reported violence informally, for example, to their coworkers and supervisors. They noted that employees who got injured or lost time from work were more likely to report a violent event formally. If hospitals understood the magnitude of underreporting and the factors that cause health care workers to underreport, they would be more knowledgeable about where to focus on violence education and prevention resources.
In its guidelines for preventing workplace violence for healthcare and social services workers, the Occupational Safety and Health Administration organization recommends that all hospitals perform a program evaluation that reviews their safety and security measures.
OSHA goes on to spell out the elements of an effective evaluation system which include (OSHA, nd):
- Establishing a uniform violence reporting system and regular review of reports
- Reviewing reports and minutes from staff meetings on safety and security issues
- Analyzing trends and rates in illnesses, injuries, or fatalities caused by violence relative to initial or “baseline” rates
- Measuring improvement based on lowering the frequency and severity of workplace violence
- Proper patient confidentiality must be maintained
- Keeping up-to-date records of administrative and work practice changes to prevent workplace violence to evaluate how well they work
- Surveying workers before and after making job or worksite changes or installing security measures or new systems to determine their effectiveness
- Tracking recommendations through to completion
- Keeping abreast of new strategies available to prevent and respond to violence in the healthcare and social service fields as they develop
- Surveying workers periodically to learn if they experience hostile situations in performing their jobs
- Complying with OSHA and state requirements for recording and reporting injuries, illnesses, and fatalities
- Requesting periodic law enforcement or outside consultant review of the worksite for recommendations on improving worker safety
American Nurses Association (ANA) Position on Workplace Violence
In 2015, the American Nurses Association, the professional organization representing the 3.6 million registered nurses, issued a position statement that advocates for a “zero tolerance” policy concerning violence against nurses in the workplace (ANA, nd).
Specific recommendations put forth by the ANA include:
- Establishing a shared and sustained commitment by nurses and their employers to a safe and trustworthy environment that promotes respect and dignity
- Encouraging employees to report incidents of violence and never blaming employees for violence perpetrated by non-employees
- Encouraging RNs to participate in educational programs, learn organizational policies and procedures, and use “situational awareness” to anticipate the potential for violence
- Developing a comprehensive violence prevention program aligned with federal health and safety guidelines, with RNs’ input
- Employers must provide a mechanism for RNs to seek support when feeling threatened
- Employers also have a responsibility to inform employees about available strategies for conflict resolution and respectful communication
- Employers are urged to offer education sessions on incivility and bullying, including prevention strategies
In 2019, the ANA convened a special #EndNurseAbuse panel, which developed a policy on the barriers to reporting workplace violence. Examples of barriers to reporting identified by the panel include the following (ANA, 2019):
- A health care culture that considers workplace violence part of the job
- A perception that violent incidents are routine. There is a lack of agreement on definitions of violence; for example, does it include verbal threats?
- Fear of being accused of inadequate performance or of being blamed for the incident and fear of retaliation by the offender and or employer
- Lack of awareness of the reporting system
- A belief that reporting will not change the current systems or decrease the potential for future incidents of violence
- A belief that the incident was not serious enough to report
- A practice of not reporting unintentional violence, e.g., incidents involving Alzheimer’s patients
- Lack of manager and employer support
- Lack of training related to reporting and managing workplace violence
- Fear of reporting supervisory workplace violence
- These barriers together create significant disincentives for RNs to report incidents of workplace violence
Removing these barriers requires a multifaceted strategy that requires the input of both nurses and their employers. How to diffuse tense situations using verbal de-escalation techniques.
When dealing with agitated patients, clinicians must quickly assess when a patient is amenable to verbal calming techniques. When they realize that they are not working, they must quickly excuse themselves and get help. Often when we approach a patient, one has no idea how the interaction will play out. However, the American Association for emergency psychiatry has provided ten key elements for verbal de-escalation
- Respect personal space – Maintain a distance of two arm's lengths and provide space for an easy exit for either party.
- Do not be provocative – Keep your hands relaxed, maintain a non-confrontational body posture, and not stare at the patient.
- Establish verbal contact – The first person to contact the patient should be the leader.
- Use concise, simple language – Elaborate and technical terms are hard for an impaired person to understand.
- Identify feelings and desires – "What are you hoping for?"
- Listen closely to what the patient is saying – After listening, restate what the patient said to improve mutual understanding.
- Agree or agree to disagree – (a) Agree with clear specific truths; (b) agree in general: "Yes, everyone should be treated respectfully; (c) agree with minority situations: "There are others who would feel like you."
- Lay down the law and set clear limits – Inform the patient that violence or abuse cannot be tolerated.
- Offer choices and optimism – Patients feel empowered if they choose in matters.
- Debrief the patient and staff.
The philosophy of yes encourages the clinician to respond to the patient affirmatively. Examples of initial clinician responses using this approach might include: “Yes, but first we should do,” “Okay, we will as soon as” or “I truly understand what you want to be done, but in my experience, it is more effective to do it another way.”
It is important to know that physical restraints can be used to calm a combative patient using other techniques. When restrained, a patient must be carefully and frequently monitored. If rapid tranquilization is required, typical antipsychotics and benzodiazepines can be utilized.
What Not To Do
There are certain things clinicians must never do, including arguing, being condescending, and commanding the patient. Also, interestingly, a threat to call security is often an invitation to aggression. Other potential mistakes include criticizing or interrupting the patient, responding defensively or taking the patient's insults personally, and not clarifying what the patient meant before responding. Finally, never lie to a patient, especially about wait times.
Do not take any threats lightly. Respond to all threats seriously and report them as appropriate. Downplaying violent behavior places all the staff at increased risk.
Putting our Knowledge to Practice
Clinical Scenario 1
You are the nurse in a busy emergency room in a large urban city. You are the triage nurse, assessing patients deciding who should be seen first. You are in the process of triaging a 28-week pregnant woman presenting with frank vaginal bleeding when an inebriated patient with a 3 inch cut on his hands he sustained from a bar fight approaches you in the waiting room. He demands to be seen first since he arrived before the pregnant patient. He does not understand why he should wait just because she is pregnant.
Clinical Scenario 2
You are a nurse working on the pediatric floor where you take care of a 6-year-old girl who sustained burn injuries a few days ago. The police visited the floor that morning and informed the nursing staff that her father was interested in their investigation, but they were having some trouble locating him. The mother reports that she is estranged from her husband and has been so for four days. Now the father arrives on the floor appears inebriated demanding to see his daughter stating he would never try to hurt her knowingly.
The sequelae of physical violence are not just limited to psychological stress. It can cause significant distress to those affected, manifesting signs and symptoms of post-traumatic stress disorder such as flashbacks avoidance of similar patients or situations.
Given that the risk factors contributing to workplace violence are multifactorial, a solution to preventing the workplace must be multifaceted with input from both the employees and managerial staff. Organizations like OSHA, the ANA, and NIOSH provide policy and evidenced-based reports which can be used as a building block for healthcare workers as they work cohesively, together with their managers, to write effective strategies applicable to their workplace setting.
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