This paper describes nurses’ experiences of violence and abuse in the workplace and how those experiences influence their abilities to care for patients. The degree of verbal abuse and physical violence that nurses routinely encounter in their work became apparent. It also became clear that abuse against nurses is an important issue that has a significant impact on nurses’ abilities to offer effective care. Findings indicated that nurses experience significant threat, frequently in the context of their work, at the hands of patients and their relatives; that verbal abuse is an almost daily occurrence; and that support from other healthcare professionals or from administration in addressing the issue, while improving somewhat, is inadequate. This work has implications not only for nurses’ health and safety but also, in the broader sense, for the profession’s ability to attract and retain nurses within the healthcare system (Henderson, 2003)
The objectives of this study were to examine perceived levels of violence in the emergency department, to obtain health care workers’ definitions of violence, to determine the effect of violence on health care workers, and to determine coping mechanisms and potential preventive strategies.
Review of Literature
This article is a commentary on an aspect of nursing that is increasingly troubling: physical abuse and the threat of violence towards nurses in the general and emergency care areas. It explores a current phenomenon and the associated factors philosophically and calls for increased research attention to changing these behaviors (Styles, 2006).
This violence comes in the form of physical and verbal violence and may stem from acute illness, excessive waiting times, overcrowding, and social/cultural behaviors. Victims of this abuse not only suffer the abuse, but also face subsequent emotional effects such as anger, anxiety, helplessness, sadness, and depression. These problems have become so commonplace that they lead to increased costs of healthcare, increased sick leave, and a negative effect on nurses’ personal lives. In addition, they may cause nurses to leave the workforce (Styles, 2006).
While nurses in emergency departments are especially prone to abuse or threats of violence, nurses in general hospital settings are also affected. Nurses are at particularly high risk of verbal and emotional abuse, physical violence, and sexual harassment in the course of their work (Kingma, 2001) It is difficult to quantify the problem because nurses have had the attitude that violence and abuse are “part of the job” and thus, many abusive activities are not even reported. Even with underreporting, the problem affects about 10% of the nursing staff. The problem seems to be particularly large in rural areas and represents more than just angry people yelling at
nurses. This includes threats with guns, knives, syringes, and needles. In the article, to the demonstration of aggressive and violent behavior (Styles, 2006)
Previous strategies to protect nurses, such as allocating funds to hire more security guards, greater police presence, aggression training for nurses, and duress alarms have not been adequate in resolving these problems. Therefore, this study calls for research to examine more closely the extent to which violent and aggressive acts occur, including the individual components and the relationships between those components in the emergency department and, in the general hospital setting, why these abusive acts have not been reported.
Once there is a greater understanding of the issues, then more effective strategies, policies, procedures, and educational programs might develop (Styles, 2006). This article demonstrates the importance of taking a public stand as the first step in describing the problem and developing a research model to explore the problem.
The research elected to use a qualitative approach for the study to ascertain how nurses interpret and respond to abuse in the work environment.
Setting: The population selected for the study consisted of nurses, who worked at a tertiary health institution. The study was conducted in the Trauma and Emergency Department where the first contact between patients and the nursing staff for both trauma and emergency cases are made in the acute sections.
Design: The phenomenological approach was used to obtain the necessary information related to individuals’ actions and interactions, through interviews and/or observation (Creswell, 1998) This approach also studies the human experiences as they are lived, and ascertain how these experiences affect them and why.
Participants and Sampling Methods: Nurses from the Trauma and Emergency Department were selected to participate in the study. The staff working in these areas is regarded as “key informants” because they are more likely to encounter incidents of abuse than the nurses in the general wards, as the units within this department are the first contact areas for traumatized and emergency patients coming to the hospital. “Key informants are individuals who possess special knowledge, status or communication skills, who are willing to share their knowledge Crabtree & Miller (1992, p.75).
Violence in the health care provision units is according to staff caused by a lack of conditions to attend to the patients and the time patients have to wait to be treated. Patients become more aggressive as they have to wait to be treated. The level of violence in the health centers and hospitals is very high but this violence is regarded as a normal situation part of the day today.
Celik et al, 2007 also stressed that colleagues were the most important source of verbally abusive behaviors while patients and patients’ relatives were the important sources of physically abusive behaviors. Disturbed mental health, decreased job performance, and headache were the more frequently reported negative effects of verbal and physical abuses on nurses. The most common reactions against abusive behaviors were anger, helplessness, humiliation, and depression. It is interesting to find that ‘did
nothing’ was the most reported coping method with verbal abuse. The findings also suggested that working in inpatient units and increasing work experience in the nursing profession were statistically significant variables increasing the likelihood of being abused physically.
Findings indicated that nurses experience significant threat, frequently in the context of their work, at the hands of patients and their relatives; that verbal abuse is an almost daily occurrence; and that support from other healthcare professionals or from administration in addressing the issue, while improving somewhat, is inadequate. This work has implications not only for nurses’ health and safety but also, in the broader sense, for the profession’s ability to attract and retain nurses within the healthcare system.
Nurses cannot manage and/or eliminate violence alone. The approach must be multidisciplinary, multisectoral, and multi-faceted. The public, professionals, and workers across sectors, employers, unions, and governments have roles to play that ensure legislation, education, research, administrative supports, and adequate resources are in place to deal with the impact of violence and to promote changes in societal attitudes (Kingma, 2001).
The nurses’ association occupational health and safety specialist, said support after an assault can be the key to helping nurses cope. Even if an assault causes no serious physical injury, she said, it can be “psychologically traumatic.” And too many
nurses, she said, complain that after a violent episode, the hospital administration turned its back on the victim (Harmacinski, 2005).
Cole of 1998 identified some of the following reasons for violence and abuse against nurses.
- Alcohol intoxication or drug abuse.
- Pain/being touched without consent or receiving treatment
- Hallucinations or thought disorders
- Verbal abuse/threatening behavior
- Speaking very loudly and /or sudden silence
Apart from obvious indicators such as alcohol or drug intoxication, it is not always easy to predict all of the likelihood of violence. However, McDonnell et al suggest “most violent incidents usually have several predictable antecedents”. These may include high levels of arousal – e.g. frustration, anger, and some form of verbal confrontation.
Violence in the emergency department is frequent and has a substantial effect on staff well-being and job satisfaction. Violence in the workplace is a well-recognized concern for health care workers, with most perpetrated by patients and, to a lesser extent, visitors. Substance abuse and psychiatric disorders are among the main factors contributing to violence in the emergency department.
Although the emergency department is recognized as a particularly violent environment, the true incidence of significant episodes of violence is unknown, since violence in this setting is underreported. In addition, definitions of violence vary.
Although verbal abuse is often not included, most studies show consistently that verbal abuse, threats, and assaults are common. For instance, Violence in the workplace is a well-recognized concern for health care workers, with most perpetrated by patients and, to a lesser extent, visitors. Substance abuse and psychiatric disorders are among the main factors contributing to violence in the emergency department.
Although the emergency department is recognized as a particularly violent environment, the true incidence of significant episodes of violence is unknown, since violence in this setting is underreported. In addition, definitions of violence vary. Although verbal abuse is often not included, most studies show consistently that verbal abuse, threats, and assaults are common. For instance, in a survey of emergency department nurses in Pennsylvania hospitals, nearly all reported verbal abuse (97%) and physical threats (94%) and a majority (66%) had been physically assaulted.
Violent incidents have a significant long-lasting effect on health care workers. Lower morale, anger, loss of confidence, burnout, time off work, disability, and change in job status has been reported. The consequences may be underestimated since each incident affects several staff.
In a survey of emergency department nurses, nearly all reported verbal abuse (97%) and physical threats (94%), and a majority (66%) had been physically assaulted. Violent incidents have a significant long-lasting effect on health care workers. Lower morale, anger, loss of confidence, burnout, time off work, disability, and change in job status has been reported. The consequences may be underestimated since each incident affects several staff.
Thompson (2004) says these experiences not only have implications for nurses’ ability to be effective in their work but may also make it difficult to attract and retain nurses, a key issue in the face of international nursing shortages.
It appears that emergency department staff work in an environment where they are constantly exposed to situations with aggressive individuals (Christopher et al, 1999)
The study showed a “persistent perception within the health care industry that these assaults are part of the job. Under-reporting may reflect a lack of institutional reporting policies, employee beliefs that reporting will not benefit them, or employee fears that employers may deem assaults the result of employee negligence or poor job performance.
Staring and eye contact, Tone and volume of voice, Anxiety, Mumbling, and Pacing provide a useful, practical nursing violence assessment framework to assist nurses in quickly identifying patients, families, and friends who have a potential for violence (Luck et al, 2007). Factors unique to the emergency department (long waits, high-stress illness, noisy environment, and nonselective 24-hour “open-door” policy) may predispose this setting to violence. Experiencing violence contributes to the sense of victimization among emergency department staff. The resultant effects are considered in their cost and implications for patient care (Christopher et al, 1999).
The responses to our survey provide a greater understanding of how emergency department staff defines violence and how violence affects them. Addressing this issue may have a beneficial effect on staff well-being, with improved job satisfaction and job retention, reduced fear, and better staff-patient relationships (Christopher et al, 1999).
The decision by contemporary Nurse to devote an entire issue to the subject of violence against nurses is a sober acknowledgment of the significance of violence as an occupational hazard for nurses. The serious nature of many attacks and the potentially catastrophic effects of violence on victims, their families, and ultimately on the nursing profession is of grave concern to all nurses
While violence was once considered ‘part of the job’ for nurses, campaigns to raise awareness in the health and aged care sectors and the community about the incidence of violence and its unacceptability as a workplace hazard are beginning to empower nurses to report violent incidents, to act to minimize risk, and to ensure their employers accept their legal obligations to provide a safe place for nurses to work and to provide care for the community (Armstrong, 1992-2008)
Nurses must assertively refuse to tolerate violence and harassment and support those who have been abused by taking individual and collective action within the workplace and through nursing organizations. National development programs should incorporate studies to prevent violence because it affects the normal functioning of the hospitals and consequently the performance of health care staff.
Financial and human conditions should be created to allow for the normal functioning of health care units. There is, of course, no way to anticipate every physical outburst or keep every suspicious patient under guard. But simply acknowledging the problems, then soliciting the advice of those on the front lines on how to deal with them, would be a good first step (Harmacinski, 2005)
Future programs need to strengthen training for these staff (Christopher et al, 1999). Nonetheless, our study raises topics for further research, such as comparing the actual incidence and nature of violence to the perception of the respondents, assessing violence prevention programs and measures in the emergency department, examining the best strategies available to recognize potentially violent situations, and testing strategies to support emergency department staff who have experienced violence. Would the unique characteristics of the emergency department necessitate changes in established programs? It is to be hoped that through the dissemination of knowledge that the power to arrest the insidious march of violence in nursing is generated. The prevalence of violence against nurses however rests uneasily with another widely acknowledged truism of nursing: that nurses are highly regarded by the community, is consistently rated as the most honest and ethical occupational group (The Morgan Poll 2005). As a discipline where caring is a central value, nursing offers the opportunity to indulge intellectual curiosity, conduct a rational inquiry, exercise problem-solving skills, and develop creativity, while retaining compassion, advocacy, and holism as core attributes (Lyneham 2001). Few people will pass through life without experiencing at some point the benefits of nursing care. Nurses more than any other health professional, care for the health of individuals and communities across the globe, and their safety should therefore be a community priority.
Armstrong, F. 1999-2008, An Industry Perspective [Article], Archive, Contemporary Nurse, Web.
Celik, S.S, Celik, Y phd, Ağırbaş, I phd, Uğurluoğlu, O msc, 2007, ‘Verbal and physical abuse against nurses in Turkey’, International Nursing Review 54 (4), 359–366.
Christopher M.B. Fernandes, MD, France Bouthillette, RN, DNS, Janet M. Raboud, PhD, Linda Bullock, RN, OH, Catherine F. Moore, RN, MSA, James M. Christenson, MD*, Eric Grafstein, MD*, Sandra Rae, MSc, Leisa Ouellet, RN*, Clay Gillrie, RN* and Michele Way, RN*, 1999, ‘Violence in the emergency department: a survey of health care workers’, CMAJ Editorial Fellowship. Web.
Cole, E. 1998, ‘Violence against nurses-what is the prognosis?’, Web.
Harmacinski, J. 2005, ‘Emergency room violence growing concern for nurses’, The Latest Developments in the Massachusetts Nursing Environment, Massachusetts Nursing Association, Web.
Henderson, A. D. 2003, ‘Nurses and Workplace Violence: Nurses’ Experiences of Verbal and Physical Abuse at Work’, Nursing Leadership (CJNL), 16(4): 82-98, Web.
Kingma, M. 2001, ‘Workplace violence in the health sector: A problem of epidemic proportion, International Nursing Review 48, 129-130.
Lyneham, J. 2001, ‘Violence in New South Wales emergency departments’, Australian Journal of Advanced Nursing 18:2: 8-17.
Luck L, Jackson D, Usher K. 2007, Components of observable behavior that indicate potential for patient violence in emergency departments, Occupational Health for Healthcare Workers, Web.
McDonnell A, McEvoy J, Dearden R. 1994, ‘Coping with violent situations in the caring environment’, Nursing Progress Is. 4, 1998.
Styles, C.R. 2006, ‘An Epidemic of Abuse and Violence: Nurse on the Front Line’, Accident and Emergency, v14 (4), Medscape Today, Web.
‘The Morgan Poll’, 2005, Community rating of most honest and ethical occupational group. Web.
Thompson, H. 4 March 2004, ‘Study shows Nurses are Regular Target of Violence’, UBC Public Affairs 50(3), The University of British Columbia, Web.