TAN Issue: May/June 1998: Features: Workplace Violence: Getting Hospitals focused on prevention

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by Susan Bruser

Once primarily limited to street crime, violence now pervades all areas of American life, from the school ground to the workplace. News reports, TV docudramas and Hollywood movies highlight the most sensational of violent acts: children gunning down children; teenagers slashing one another; spouses torturing children; workers killing coworkers.

In the midst of this maelstrom, people would ordinarily expect to find refuge from violence in health care settings. After all, hospitals exist to treat the sick, injured and infirm. Sadly, the realities of a violent society do not stop at the hospital entrance. And the victims of in-hospital violence are often the nurses who provide care.

In the United States, approximately one million workplace assaults occur annually. Homicide is now the second leading cause of occupational death; in 1994, more than 1,000 murders occurred at work. While convenience store clerks and taxicab drivers are at greatest risk of homicide, health care and social service workers have the highest incidence of injuries from workplace assaults. The Bureau of Labor Statistics notes that in 1993, almost two-thirds (64 percent) of non-fatal assaults occurred in hospitals, nursing homes and residential care facilities. And experts believe workplace assaults are significantly under-reported.

The price nurses pay

Nursing is a stressful profession, and on-the-job assaults are not new. Emergency rooms and psychiatric units have always witnessed violence. What is new is that violence now pervades the hospital. Robbery, verbal abuse, physical attack, sexual harassment, rape and even murder occur in hospitals. Says Colorado Nurses Association (CNA) member Victoria Carroll, MSN, RN, "No hospital unit and no hospital -- large or small, urban or rural -- is immune. Nurses are being assaulted wherever there are patients, friends and families." Carroll, a nursing consultant in workplace violence, directed the 1995 Kansas State Nurses Association Violence Assessment in Hospitals Project funded by the ANA. An update of this important study will be published shortly.

Fellow CNA member Paula Jo Curlee, now an RN at Vencor Hospital in Colorado, concurs with Carroll. "RNs are trained to handle psychiatric patients. It's everyone else we should be worried about." Curlee speaks from experience. She was twice the victim of patient violence, once losing two teeth when a drunk patient kicked her while she attempted to remove his boots, the second time losing four teeth and being beaten and kicked unconscious by a pregnant patient. In addition, Curlee was assaulted by an angry husband who "grabbed me by the throat and basically dangled me in the air."

Says Curlee, "My experiences may be extreme, but they're not unusual. Most of the nurses I know have been threatened or assaulted at some point." Violence

The physical injuries resulting from assault may heal quickly, but the emotional trauma can be long-term. In addition, verbal abuse -- which is sometimes not recognized as being on the continuum of violence -- can leave its own emotional imprint. Feelings of anger, denial, depression, fear and powerlessness, thoughts about changing professions and decisions to leave nursing are not unusual among nurses who have been attacked.

Marilyn Lewis Lanza, DNSc, RN, assistant chief of nursing service for research at the Edith Nourse Rogers Memorial Veterans Hospital and a member of the Massachusetts Nurses Association, studies nurses who have been assaulted. Her research finds that some nurses feel assault is part of the job, while others don't allow themselves to address their feelings for fear of being unable to perform their duties. The one constant is blame. Lanza notes that most assaulted nurses attribute blame to themselves or their supervisors. Coworkers and administrators also place blame, often on the victim, to protect themselves from feeling vulnerable to random violence.

Key to overcoming these negative feelings is availability of adequate support services. Employee assistance professionals, social workers, clinical nurse specialists, psychologists and psychiatrists can provide one-on-one counseling. Lanza notes that meeting with coworkers and a counselor is also important because it enables the victim and peers to talk about the incident, learn from it and give each other support.

Factors that contribute to hospital violence

Several factors are associated with violence in hospitals. External conditions include an increasingly violent society, the growing prevalence of handguns and other weapons and high-crime neighborhoods. In-hospital factors include low staffing levels, greater numbers of very sick or dangerous patients, the availability of money and drugs, nurses working alone, poorly lit facilities and parking lots and unsecured exits and entrances.

News reports give the mistaken impression that nurses are being bruised, lacerated and worse by their husbands, ex-husbands, boyfriends or ex-boyfriends or coworkers. In reality, assailants are much more likely to be patients and their frustrated and distraught family members and friends.

Compounding the problem, some hospitals do not recognize the problem and, therefore, fail to take the necessary steps to prevent violence. Specifically, some do not staff adequately, do not provide security backup, do not educate nurses to recognize, diffuse and manage potentially violent situations and do not provide counseling following an assault. Curlee was given no preparedness training before and no counseling after her assaults. As she explains it, "At both hospitals, I filled out an incident report, went to the ER and dentist and was back at work the next day eating baby food for lunch."

Reducing workplace violence: Making it happen

Reducing workplace violence is a realistic objective. True, nurses, administrators and other hospital staff cannot, by themselves, overcome the poverty, insufficient education and other problems that underlie societal violence. However, they can correct in-hospital conditions that provoke violence (such as inadequate staffing), train nurses to manage violence when it occurs and provide the support nurses need following an assault.

Thurman Hampton, CEO of Community Service Associates, Inc., a public safety consulting firm, says that changing the philosophy of hospital administrators and staff is critical. "Everyone needs to understand that a nurse who has been hit or kicked by a patient has been assaulted, that assault is violence and that violence is not part of the job. When this basic philosophy is adopted, the need for education becomes clear to administrators, nurses and all staff."

Recognizing the prevalence of workplace violence, the Occupational Safety and Health Administration (OSHA) issued guidelines in 1996 on preventing workplace violence for health care and social service workers (OSHA publication 3148). Individual states and professional organizations also have published guidelines on reducing violence in health care settings. (See box.)

Critical to the success of violence prevention is active participation by nurses. The adage "the squeaky wheel gets the grease" is as true today as ever. Zero tolerance for workplace violence should be the rule. Nurses can play a critical role to help make it happen. Call (800) 274-4ANA to request a copy of ANA's brochure Workplace Violence: Can You Close the Door on It? The brochure (WP-5) and the OSHA publication on workplace violence also can be accessed through the ANA's health and safety home page on its Nursing World website: www.nursingworld.org/MainMenuCategories/OccupationalandEnvironmental.aspx.

Susan Bruser is a Washington, D.C.-based freelance writer specializing in health care reporting.