Nurses and Workplace Violence

1. Nurses andWorkplace Violence By Michele M. Valentino, MSN,CNS, BC, NP

2. Objectives • Identify scope of WPV in the health care settings • Identify the role of professional nursing organizations • Describe violence in psychiatric, ED & Homecare settings • Interventions for reducing WPV • Recommendations for reducing WPV

3. SCOPE of the Problem • Violence is pervasive in our world!!!!! • Smoyak & Blair wrote in 1992 that violence was epidemic with US Dept. of Justice statistics on violence increasing each year. • 2002 US Dept. of Labor reported nearly 2 million acts of nonfatal work-related violent acts annually. • 2006 ICN reported that occupational violence is a major worldwide public health problem

4. Scope • Work-related violence is the 3rd leading cause of occupational injury fatality in the US • 2nd leading cause of death for women at work • 10 yr study of rape in the workplace in Washington State found 11% of victims were health care workers in hospitals or other care facilities. • 2007 Hatch-Maillette found 63% of sample reported sexual threat & 84% reported a past incident of physical or sexual assault

5. Scope • According to the Department of Justice (Myers, 1996), nurses are identified as the occupation experiencing the greatest number of assaults by a client, patient, or student served by the facility. • These results were further validated by the Occupational Safety and Health Administration • (Trape, 1998) stating “more assaults occur to health care and social services industries than any other,” with nurses experiencing the most assaults.

6. Scope • In addition, mental health professionals experience assault & robbery at the alarming rate of 79.5% (Lanza & Campbell, 1991). • Workplace violence has been linked to decreased job performance and job satisfaction, as well as increased absenteeism and mental health issues among doctors, nurses, and other health care professionals (Bartholomew, 2006).

7. Scope • Nurses are exposed to, or are victims of, various types of abuse from sources that include patients, visitors, other nurses, physicians, or others in the work environments. • As the incidence and severity of workplace violence rises in all areas, the issue becomes of significant concern in healthcare settings (Jackson, Clare, & Mannix, 2000). • Over 2 million workers are victims of harassment, threats, or assault each year

8. Scope • the actual scope of workplace violence is difficult to capture since more than 50-80% of acts may go unreported (Gates, 2004, Lanza & Campbell, 1991, Gates, Ross & McQueen, 2006).

9. Background • Violence in the workplace is one of the most dangerous hazards facing nurses (McPhaul and Lipscomb, 2004). • Violence against all health care workers presents a special challenge. Nurses experience the most assaults. • (U.S. Department of Justice Federal Bureau of Investigation 2004, 54) of health care workers. • In 1999, 2,637 nonfatal assaults on hospital workers occurred in the following settings: Hospitals: rate of 8.3 assaults/10,000 workers Private sector industries: 2 assaults/10,000 workers (Centers for Disease Control and Prevention/NIOSH, 2002, 1)

10. Hospitals Canadian Study (Hesketh et al., 2003) • Emergency Nurses 39.9 percent were threatened with assault 21.9 percent were physically assaulted • Medical Surgical Nurses 22.6 percent were threatened with assault 24.2 percent were physically assaulted • Psychiatry Nurses 20.3 percent were threatened with assault 43.3 percent were physically assaulted

11. Hospitals Florida Study (May and Grubbs, 2002) • Emergency Nurses 100 percent were verbally assaulted 82 percent were physically assaulted • ICU Nurses 85.2 percent were verbally assaulted 77.8 percent were physically assaulted • Floor Nurses 80.6 percent were verbally assaulted 63.3 percent were physically assaulted

12. References • Centers for Disease Control and Prevention/NIOSH. 2002. Violence: Occupational Hazards in Hospitals. CDC: National Institute for Occupational Safety and Health, No. 2002-101. Retrieved February 16, 2006, from www.cdc.gov/niosh/2002-101.html. • Hesketh, K., S. M. Duncan, C. A. Estabroks, et al. 2003. Workplace violence in Alberta and British Columbia hospitals. Health Policy 63: 311.321. • May, D., and L. Grubbs. 2002. The extent, nature, and precipitating factors of nurse assault among three groups of registered nurses in a regional medical center. Journal of Emergency Nursing 28(1): 11.17. • McPhaul, K., J. Lipscomb. 2004. Workplace Violence in Health Care: Recognized but Not Regulated. Online • Journal of Issues in Nursing 9 (3) Manuscript 6. Retrieved February 16, 2006, from www.nursingworld.org/ • ojin/topic25/tpc25_6.htm. • U.S. Department of Justice Federal Bureau of Investigation. 2004. Workplace Violence: Issues in • Response. Retrieved February 16, 2006, from www.fbi.gov/page2/march04/violence030104.htm.

13. Incidence • Bureau of Justice workplace assaults injure 1.7 million workers (2001) • Health care & social service industries are 2nd only to law enforcement for WPV (2003) • Nearly 500,000 nurses become victims of violence in workplace annually. • Nurses are 3 X more likely to be victims of violence than any other professional group

14. Incidence • Nursing Management 2008 1400 respondents 74% experienced some form of violence in the workplace (Hader, 2008). Included US & 17 other countries. • 51-75% were bullying, intimidation & harassment. • 26% = physical violence • Weapons = 5.6 to 7.5 % • Perpetrators = 53/2% patients, 52% colleagues, 49% physicians, visitors 47%, other health care workers (37.7%)

15. Incidence • Joint Commission found that more than 50% of nurses reported verbal abuse ( AACCN, 2005) • Survey of 303 nurses, 53% reported being bullied at work(Vessey, Demarco, Gaffney & Budin, in press)

16. Attention to WPV • ICN, AAN, ANA have advocated for increased protective regulations & research to study effective risk management programs. • The Center for American Nurses has issued a statement on WPV & a position statement on Bullying & Horizontal Violence.

17. Attention to WPV • AORN 2003 & 2007 • Am. Assoc. of Critical-Care Nurses (2004) • National Student Nurses Assoc 2006 • Code of Ethics for nurses ( ANA 2001) • Joint Commission 2007 • APNA Position Statement (Oct. 2008)

18. OHIO NURSES ASSOCIATION (ONA) • SCDONA (Stark-Carroll District of ONA) wrote a reference item for convention in 2007 concerning WPV • ONA requested that SCDONA write & submit a position statement on WPV • adopted by ONA in 2008

19. Position Statement on WPVNursing Practice Statement NP 83 Developed: 2007 Revised: The American Nurses Association’s Code of Ethics for Nurses states, in part: The nurse, in all professional relationships, practices with compassion and respect for the inherent dignity, worth, and uniqueness of every individual, unrestricted by considerations of social or economic status, personal attributes, or the nature of health problems. The nurse’s primary commitment is to the patient, whether an individual, family, group, or community. The nurse promotes, advocates for, and strives to protect the health, safety, and rights of the patient. The nurse owes the same duties to self as to other, including the responsibility to preserve integrity and safety, to maintain competence, and to continue personal and professional growth. The nurse participates in establishing, maintaining, and improving health care environments and conditions of employment conducive to the provision of quality health care and consistent with the values of the profession through individual and collective action. The profession of nursing, as represented by associations and their members, is responsible for articulating nursing values, for maintaining the integrity of of the profession and its practice, and for shaping social policy.

20. American Nurses Association’s Bill of Rights for Registered Nurses • Nurses have the right to practice in a manner that fulfills their obligations to society and to those who receive nursing care. • Nurses have the right to freely and openly advocate for themselves and their patients, without fear of retribution. • Nurses have the right to a work environment that is safe for themselves and their patients

21. Workplace Violence One of ONA's goals is to prevent violence in the workplace, and ONA supports the following objectives: Pursuit and support of legislation making the assault of any nurse a felony offence, punishable as determined by law; Development of programs to support nurses who report assaults and assistance with the process; Development of workplace standards through OSHA, OHA, and the Ohio Department of Health, and; Development of materials to educate nurses to their rights and legal remedies.

22. Workplace Violence Information & Resources • ONA's Nursing Practice Statement on Workplace Violence(Members Only) • Behaviors that Undermine a Culture of Safety (Joint Commission Sentinel Event) • The Center for American Nurses Position Statement on Lateral Violence and Bullying in Nursing Work Environments • Guidelines for Preventing Workplace violence for Health Care & Social Services Workers • Violence Against Nurses: The Silent Epidemic (Independent Study) • NIOSH Occupational Hazards in Hospitals: Exposure to Stress

23. Resources • OSHA (2002) has information on preventing and controlling workplace violence in a fact sheet on workplace violence, available at http://www.osha.gov/OshDoc/data_General_Facts/factsheetworkplace-violence.pdf. OSHA guarantees all workers a “safe & healthful workplace”. • Employers must provide a safe workplace using written policies, employee training, proper staffing, and follow-up of any incidents.

24. Resources • The Center for American Nurses (Carroll, 2003) has a two page print-out on their website http://www.centerforamericannurses.org entitled “Guidelines for Preventing Workplace Violence for Health Care and Social Service Workers”. The four main components are: 1. Management commitment and employee involvement 2. Workplace analysis 3. Hazard prevention and control 4. Safety and health training

25. Resources • The American Nurses Association’s has a bulleted brochure that they allow the Constituent Member Associations to print with their logo. It is titled “Workplace Violence, Can You Close the Door on It?” (ONA, 1996). It includes information on “Know your Patients,” “Steps to a Safer Work Place,” and “Addressing Workplace Violence.”

26. Related Files • Workplace Violence Data Collection Form (Adobe PDF File)Preventing Workplace Violence Brochure (Adobe PDF File)Workplace Violence in the Health Care Setting (Adobe PDF File)Occupational Hazards in Hospitals (Adobe PDF File)Nurses and Workplace Violence Fact Sheet (Adobe PDF File)NIOSH Occupational Hazards in Hospitals: Exposure to Stress (Adobe PDF File)The Center's Position Statement on Lateral Violence and Bullying (Adobe PDF File)

27. APNA Task Force on WPV • 2007 survey by APNA, Safety was one of the top issues for front line providers • I was honored to chair this task force May 2007 • Call to members Response of 150 persons • 25 members selected for steering committee • Expert Consultant Panel • 3 areas = Psychiatric (inpatient, outpatient, forensic, state-funded), other health care settings (ED’s and homecare), & schools and universities.

28. APNA Task Force on WPV • ROL from 1970 to 1990 –most articles described characteristics of units where violence occurred & described staff response to assault. • Pressing need for research describing successful violence prevention interventions

29. APNA Task Force on WPV • ROL using key words of “psychiatric, nursing, & violence” in the data bases in CINAHL, PsycINFO, and Academic Search Premier.

30. What is Horizontal Violence (HV)? • Bullying is repetitive horizontal or lateral violence and it can be detrimental to a person’s physical or mental well-being ( Center for Am. Nurses) • DISRUPTIVE BEHAVIOR = behavior that interferes with effective communication among healthcare providers and negatively impacts performance & outcomes. Bullying is repetitive horizontal or lateral violence and it can be detrimental to a person’s physical or mental well-being ( Center for Am. Nurses)

31. Bullying

32. Horizontal Violence • Now receiving more attention • JAHCO addresses “disruptive behavior” (July 9, 2008) JAHCO uses the term “zero tolerance”

33. Horizontal Violence • Horizontal Violence, a term used to identify violence that occurs between peers, is seen when nurses “bully” their coworkers. • Behaviors exhibited with horizontal violence may include criticizing, sabotaging, undermining, infighting, blaming, scapegoating, intimidation and bickering.

34. Horizontal Violence • The 10 most frequent forms of horizontal violence are nonverbal innuendo, verbal affront, undermining activities, withholding information, sabotage, infighting scapegoating, backbiting,failure to respect privacy, and broken confidences (Griffin, 2004).

35. Examples of bullying behaviors(Hastie, 2002;Workplace Bullying Institute, 2003) • Being accused of errors made by someone else • Nonverbal intimidation, included being stared at or glared at • Being belittled • Having thoughts or feelings ignored • Being excluded from activities or conversations

36. Who is the Bully? Colleague? Supervisor? Physician?

37. Horizontal Violence • Use of cue cards & scripting for responses • Educate nurses & students about it • Create an infrastructure to support managers and staff • Assertiveness training • Appraisal of risky situations • Communication skills Training

38. Interventions • Nsg Curriculum to include: awareness-raising & empowering strategies Educate Nurses emphasizing non-hierarchical leadership & supportive relationships.

39. The cycle of Violence • Each of us tolerates the behaviors of others a bit differently. However, if the behavior is offensive to you, or undermines you and your job in any way, it needs to be reported to your manager. • Speaking up is difficult, especially if one has to face the bully everyday in the work environment. Fear of retaliation from the perpetrator.

40. Intimidation

41. Remember the Bully

42. Complications of WPV

43. Develop a New Culture in Nursing • To gain self-confidence, nurses need to articulate clearly & confidently their common vision of nursing and its future (Buresh & Gordon 2000) Nurses must “PAY IT FORWARD” – praise each other for jobs well done VALUE each other & the work of others New staff need mentored in a kind, nurturing manner

44. Create A New Culture in Nursing • Mentor new hires and new grads • Appreciate diverse points of views • Value the differences in colleagues from various generations. It is not a burden it is an advantage.

45. Creating a New Culture in Nursing • Express pride in being a nurse • Accept and celebrate compliments about good patient care • Actively compliment others for work well done • Look for and acknowledge improvements to the system • Be an ambassador to those outside the profession about the true contribution nurses make to quality patient care.

46. Interventions for Horizontal Violence • Gain control • Get help from your employer • Make a plan for action • Take action • Confront the aggressor • Make a formal written complaint • Take legal action

47. Be Savvy if necessary • Solicit support from family & friends • Consult an outside physician or therapist • Solicit witness statements • Confront the bully • File the internal complaint • Preparing of the case against the bully • “Rule of 2”meeting presenting your case • Taking your case public

48. Interventions for Horizontal Violence • Replace your own internalized misperception with a belief that we are gifted, dedicated and highly skilled professionals who have struggled against great odds • Resist messages from coworkers or superiors that denigrate your professionalism or that of the nursing profession • Be a supportive colleague

49. Interventions with Horizontal Violence • Direct concerns about workplace negativity clearly and concisely to appropriate individuals. • Develop an understanding that “rocking the boat” can be the first step in the service of positive change. • Start confronting problems, not people

50. Interventions for Horizontal Violence • Support, insight, and connection can help nurses change the cycle that impinges their own empowerment . • Develop a positive personal and professional identity • Develop Assertive Behaviors