In nursing, does violence 'come with the job'?
A high rate of verbal, physical assault
Every day, nurses face a barrage of threats, insults and assaults from patients or visitors, yet almost half never report verbal or physical assaults. In a survey at five Inova Health System hospitals in Virginia, one in five nurses gave this as their explanation: Violence comes with the job.1
Yet workplace violence takes a toll on nurses and leads many to leave their jobs or their profession, the survey found. About half of the nurses (55%) said they were fearful of being physically injured. One-third of the nurses — and 80% of emergency nurses — said they had considered leaving the hospital because of violence, and almost one in 10 (8.8%) said they had considered leaving their profession.
Coping with violence could become even more problematic as the health care workforce ages, says Karen Speroni, a biomedical research consultant who was a nursing research scientist at Inova Loudoun Hospital in Leesburg, VA. "It's going to be harder to provide support for these older nurses if we're not doing more to keep their workplace environment safe," she says.
In light of the survey results, Inova Loudoun Hospital is focusing on better training, security and awareness of the importance of reporting.
"[Detecting] early warning signs and trying to mitigate aggression as much as possible are the only ways we're going to reduce the violence," says Lisa Dugan, PhD, RN, NEA/BC, chief nursing officer at Inova Loudoun and a member of the hospital's workplace violence workgroup.
Kicked, grabbed, scratched and pinched
To take steps to reduce violence, it's important to know more about where and how often violent incidents occur and who is most at risk, Speroni says. Recent shootings at hospitals around the country also highlighted the need for awareness and security, says Dugan.
In the fall of 2011, backed by a grant from the Emergency Nurses Association Foundation, Speroni launched a survey of the system's 5,000 nurses; 762 responded, including 92 emergency nurses. Almost all the emergency nurses (96.7%) and three-fourths of the non-emergency nurses (73%) reported experiencing at least one incident of verbal or physical violence in the past year.
The traditional route for reporting workplace injury produces a vast undercount. Only 2% of the system's nurses had reported a workplace violence incident to employee health. Those were most likely to be incidents that required medical treatment or days away from work, says Speroni.
Yet a third or more of emergency nurses (and a quarter or more of non-emergency nurses) reported having been kicked, scratched, grabbed or pinched in the past year.
When asked about barriers to reporting, 26% said it was too inconvenient and 18% said they felt no one reports and nothing would be done in response to reports.
In fact, Inova Loudoun Hospital has an electronic incident reporting system that allows reporting of near-misses or incidents related to both patient safety and worker safety — and those reports can be anonymous, says Dugan. There is also a 24-hour telephone hotline for the same purpose. The hospital now plans to conduct an awareness campaign to underscore the importance of reporting, she says.
"We want to know about these things so that we can identify trends and problem areas," she says.
Nurses want to feel support from their managers as they cope with day-to-day verbal and physical violence, Speroni says. "Management can take additional steps to make sure nurses understand there is a need to report, and that something would be done with the reporting," she says.
Dementia linked to risk
The greatest risk comes from patients who are confused or disoriented due to dementia or Alzheimer's Disease. Those patients may be encountered in any part of the hospital, says Speroni.
Patients or visitors under the influence of alcohol or drugs are also involved in many of the incidents of aggression, she says.
Inova Loudoun Hospital launched an online educational module for all employees to learn about de-escalating aggressive behavior. The hospital also gathered a workgroup of employee health, security, human resources, risk management, nursing, and ED physicians to look for other interventions.
New nurses' badges have a distress button that connects into the nursing call system. Nurses also can call for a Code Strong, which brings security and other support to respond to aggression.
The hospital is reviewing its physical elements, such as surveillance cameras, and how and when employees should search patient belongings for weapons.
Annual employee health encounters offer an opportunity to ask about verbal or physical violence, says Dugan. "We need to do everything we can for our nurses to be able to provide the best care, so they feel physically and psychologically safe in the environment," says Speroni.
- Speroni KG, Fitch T, Dawson E, et al. Incidence and cost of nurse workplace violence perpetrated by hospital patients or patient visitors. Journal of Emergency Nursing 2013; in press. Available at www.jenonline.org/article/S0099-1767(13)00216-X/abstract. Accessed on January 13, 2014.