Patient Violence: It’s Not All in a Day’s Work (Strategies for reducing patient violence and creating a safe workplace)

By Lori Locke, MSN, RN, NE-BC; Gail Bromley, PhD, RN; Karen A. Federspiel, DNP, MS, RN-BC, GCNS-BC
Reprinted from American Nurse Today, Volume 13, Number 5

Robert, a 78-year-old patient, requests help getting to the bathroom. When the nurse, Ellen, enters the room, Robert’s lying in bed, but when she introduces herself, he lunges at her, shoves her to the wall, punches her, and hits her with a footstool. Ellen gets up from the floor and leaves the patient’s room. She tells her colleagues what happened and asks for help to get the patient to the bathroom. At the end of the shift, Ellen has a swollen calf and her shoulder aches. One of her colleagues asks if she’s submitted an incident report. Ellen responds, “It’s all in a day’s work. The patient has so many medical problems and a history of alcoholism. He didn't intend to hurt me. What difference would it make if I filed a report?”

These kinds of nurse-patient interactions occur in healthcare settings across the United States, and nurses all too frequently minimize their seriousness. However, according to the National Institute for Occupational Safety and Health, “…the spectrum [of violence]…ranges from offensive language to homicide, and a reasonable working definition of workplace violence is as follows: violent acts, including physical assaults and threats of assault, directed toward persons at work or on duty.” In other words, patient violence falls along a continuum, from verbal (harassing, threatening, yelling, bullying, and hostile sarcastic comments) to physical (slapping, punching, biting, throwing objects). As nurses, we must change our thinking: It’s not all in a day’s work.

This article focuses on physical violence and offers strategies you can implement to minimize the risk of being victimized.

Consequences of Patient Violence

In many cases, patients’ physical violence is life-changing to the nurses assaulted and those who witness it. (See Alarming statistics.) As a result, some nurses leave the profession rather than be victimized—a major problem in this era of nursing shortages.

Too frequently, nurses consider physical violence a symptom of the patient’s illness—even if they sustain injuries—so they don’t submit incident reports, and their injuries aren’t treated. Ultimately, physical and psychological insults result in distraction, which contributes to a higher incidence of medication errors and negative patient outcomes. Other damaging consequences include moral distress, burnout, and job dissatisfaction, which can lead to increased turnover. However, when organizations encourage nurses to report violence and provide education about de-escalation and prevention, they’re able to alleviate stress.

ALARMING STATISTICS

The statistics around patient violence against nurses are alarming.

  • 67% of all nonfatal workplace violence injuries occur in healthcare, but healthcare represents only 11.5% of the U.S. workforce.
  • Emergency department (ED) and psychiatric nurses are at highest risk for patient violence.
  • Hitting, kicking, beating, and shoving incidents are most reported.
  • 25% of psychiatric nurses experience disabling injuries from patient assaults.
  • At one regional medical center, 70% of 125 ED nurses were physically assaulted in 2014.

Sources: Emergency Nurses Association (ENA) Emergency department violence surveillance study 2011; ENA Workplace violence toolkit 2010; Gates 2011; Li 2012.

Workplace Violence Prevention

Therapeutic communication and assessment of a patient’s increased agitation are among the early clinical interventions you can use to prevent workplace violence. Use what you were taught in nursing school to recognize behavioral changes, such as anxiety, confusion, agitation, and escalation of verbal and nonverbal signs. Individually or together, these behaviors require thoughtful responses. Your calm, supportive, and responsive communication can de-escalate patients who are known to be potentially violent or those who are annoyed, angry, belligerent, demeaning, or are beginning to threaten staff.(See Communication strategies.)

Other strategies to prevent workplace violence include applying trauma-informed care, assessing for environmental risks, and recognizing patient triggers.

Trauma-informed Care

Trauma-informed care considers the effects of past traumas patients experienced and encourages strategies that promote healing. The Substance Abuse and Mental Health Services Administration says that a trauma-informed organization:

  • realizes patient trauma experiences are widespread
  • recognizes trauma signs and symptoms
  • responds by integrating knowledge and clinical competencies about patients’ trauma
  • resists retraumatization by being sensitive to interventions that may exacerbate staff-patient interactions

This approach comprises six principles: safety; trustworthiness and transparency; peer support; collaboration and mutuality; empowerment, voice, and choice; and cultural, historical, and gender issues. Applying these principles will enhance your competencies so that you can verbally intervene to avoid conflict and minimize patient retraumatization. For more about trauma-informed care, visit samhsa.gov/nctic/traumainterventions.

Environmental Risks

To ensure a safe environment, identify objects in patient rooms and nursing units that might be used to injure someone. Chairs, footstools, I.V. poles, housekeeping supplies, and glass from lights or mirrors can all be used by patients to hurt themselves or others. Remove these objects from all areas where violent patients may have access to them.

Patient Triggers

Recognizing and understanding patient triggers may help you de-escalate volatile interactions and prevent physical violence. Common triggers include:

  • Expectations aren’t met
  • Perceived loss of independence or control
  • Upsetting diagnosis, prognosis, or disposition
  • History of abuse that causes an event or interaction to retraumatize a patient

Predisposing factors:

  • Alcohol and substance withdrawal
  • Psychiatric diagnoses
  • Trauma
  • Stressors (financial, relational, situational)

Share detailed information about specific patient triggers during handoffs, in interdisciplinary planning meetings, and with colleagues in safety huddles.

What Should You Do?

You owe it to yourself and your fellow nurses to take these steps to ensure that your physical and psychological needs and concerns are addressed:

  • Know the definition of workplace violence.
  • Take care of yourself if you’re assaulted by a patient or witness violence.
  • Discuss and debrief the incident with your nurse manager, clinical supervisor, and colleagues.
  • Use the healthcare setting’s incident reporting to report and document violent incidents and injuries.
  • File charges based on your state’s laws.

Your organization should provide adequate support to ensure that when a nurse returns to work after a violent incident, he or she is able to care for patients. After any violent episode, staff and nurse leaders should participate in a thorough discussion of the incident to understand the dynamics and root cause and to be better prepared to minimize future risks. Effective communication about violent patient incidents includes handoffs that identify known risks with specific patients and a care plan that includes identified triggers and clinical interventions.

Influence Organizational Safety

You and your nurse colleagues are well positioned to influence your organization’s culture and advocate for a safe environment for staff and patients. Share these best practices with your organization to build a comprehensive safety infrastructure.

  • Establish incident-reporting systems to capture all violent incidents.
  • Create interprofessional workplace violence steering committees.
  • Develop organizational policies and procedures related to safety and workplace violence, as well as human resources support.
  • Provide workplace violence-prevention and safety education using evidence-based curriculum.
  • Design administrative, director, and manager guidelines and responsibilities regarding communication and staff support for victims of patient violence and those who witness it.
  • Use rapid response teams (including police, security, and protective services) to respond to violent behaviors.
  • Delineate violence risk indicators to proactively identify patients with these behaviors.
  • Create scorecards to benchmark quality indicators and outcomes.
  • Post accessible resources on the organization’s intranet.
  • Share human resources contacts.

Advocate for the Workplace You Deserve

Physically violent patients create a workplace that’s not conducive to compassionate care, creating chaos and distractions. Nurses must advocate for a culture of safety by encouraging their organization to establish violence-prevention policies and to provide support when an incident occurs.

You can access violence-prevention resources through the American Nurses Association, Emergency Nurses Association, Centers for Disease Control and Prevention, and the National Institute for Occupational Safety and Health. Most of these organizations have interactive online workplace violence-prevention modules. (See Resources.) When you advocate for safe work environments, you protect yourself and can provide the care your patients deserve.

The authors work at University Hospitals of Cleveland in Ohio. Lori Locke is the director of psychiatry service line and nursing practice. Gail Bromley is the co director of nursing research and educator. Karen A. Federspiel is a clinical nurse specialist III.


Selected References
Cafaro T, Jolley C, LaValla A, Schroeder R. Workplace violence workgroup report. 2012. apna.org/i4a/pages/index.cfm?pageID=4912
Emergency Nurses Association. ENA toolkit: Workplace violence. 2010. goo.gl/oJuYsb
Emergency Nurses Association, Institute for Emergency Nursing Research. Emergency Department Violence Surveillance Study. 2011. bit.ly/2GvbJRc
Gates DM, Gillespie GL, Succop P. Violence against nurses and its impact on stress and productivity. Nurs Econ. 2011;29(2):59-66.
National Institute for Occupational Safety and Health. Violence in the workplace: Current intelligence bulletin 57. Updated 2014. cdc.gov/niosh/docs/96-100/introduction.html
Occupational Safety and Health Administration. Guidelines for Preventing Workplace Violence for Healthcare and Social Service Workers. 2016. osha.gov/Publications/osha3148.pdf
Speroni KG, Fitch T, Dawson E, Dugan L, Atherton M. Incidence and cost of nurse workplace violence perpetrated by hospital patients or patient visitors. J Emerg Nurs. 2014;40(3):218-28.
Substance Abuse and Mental Health Services Administration. Trauma-informed approach and trauma-specific interventions. Updated 2015. samhsa.gov/nctic/traumainterventions
Wolf LA, Delao AM, Perhats C. Nothing changes, nobody cares: Understanding the experience of emergency nurses physically or verbally assaulted while providing care. J Emerg Nurs. 2014;40(4):305-10.

COMMUNICATION STRATEGIES

Effective communication is the first line of defense against patient violence. These tips can help:

  • To build trust, establish rapport and set the tone as you respond to patients.
  • Meet patients’ expectations by listening, validating their feelings, and responding to their needs in a timely manner.
  • Show your patients respect by introducing yourself by name and addressing them formally (Mr., Ms., Mrs.) unless they state another preference.
  • Explain care before you provide it, and ask patients if they have questions.
  • Be attentive to your body language, gestures, facial expressions, and tone of voice. Patients’ behavior may escalate if they perceive a loss of control, and they may not hear what you say.
  • Control your emotions and maintain neutral, nonthreatening body language.
  • Strive for communication that gives the patient control, when possible. Example: “Which of your home morning routines would you like to follow while you’re in the hospital? Would you like to wash your hands and face first, eat your breakfast, and then brush your teeth?”
  • Offer a positive choice before offering less desirable ones. Example: “Would you prefer to talk with a nurse about why you’re upset, or do you feel as though you will be so angry that you need to have time away from others?”
  • Only state consequences if you plan to follow through.
  • Listen to what patients say or ask, and then validate their requests.
  • Discuss patients’ major concerns and how they can be addressed to their satisfaction.

Despite these strategies, patients may still become upset. If that occurs, try these strategies to deescalate the situation before it turns violent.

Nonverbal communication. “I see from your facial expression that you may have something you want to say to me. It’s okay to speak directly to me.”

Challenging verbal exchange. “My goal is to be helpful to you. If you have questions or see things differently, I’m willing to talk to you more so that we can understand each other better, even if we can’t agree with one another.”

Perceptions of an incident or situation. “We haven’t discussed all aspects of this situation. Would you like to talk about your perceptions?”

RESOURCES

American Nurses Association (ANA) (goo.gl/NksbPW): Learn more about different levels of violence and laws and regulations, and access the ANA position statement on incivility, bullying, and workplace violence.

Centers for Disease Control and Prevention (cdc.gov/niosh/topics/vio-lence/training_nurses.html): This online course (“Workplace violence prevention for nurses”) is designed to help nurses better understand workplace violence and how to prevent it.

Emergency Nurses Association (ENA) toolkit (goo.gl/oJuYsb): This toolkit offers a five-step plan for creating a violence-prevention program.

The Joint Commission Sentinel Event Alert: Physical and verbal violence against health care workers (bit.ly/2vrBnFw): The alert, released April 17, 2018, provides an overview of the issue along with suggested strategies.