Not long ago, nurses' concerns related to personal safety were focused on traveling to and from the workplace. Regardless of shift assignment, nurses working in the hospital setting frequently found themselves enroute at times infrequently traveled by others in the workforce. The risks involved with using public transportation or walking to one's automobile were acknowledged by both nurses and their employers. Once at work however, nurses perceived themselves to be in a safe haven and were free to concentrate their energies on caring for the patients for whom they were responsible.
This no longer is the case, as the environment within the health care arena is fraught with violence and potential risk. Violence affecting nurses in the workplace continues to escalate. Nurses must become aware of the risks involved and take measures to respond to the hazards they encounter on a regular basis. The American Nurses Association (ANA) has recommended the development and implementation of violence prevention programs at all health care facilities and the establishment of a standard definition of violence against health care workers (Cassette, 1993). Because of the realities of these increasing risks, undergraduate nursing curricula must address the hazards present in the environment and incorporate content that prepares students to respond to the actual and potential threats to their safety encountered in the health care arenas. In discussing the nursing diagnosis "potential for violence directed at others or setf-directed" accepted by the North American Nursing Diagnosis Association (NANDA) in 1990, Hovey (1994) suggests that nursing students need to be better prepared to identify potential violence. The purpose of this article is to review the phenomena of violence in various health care settings and to suggest approaches to prepare students to effectively respond to these challenges.
Incidence - The incidence of violent and assaultive behavior on psychiatric units has been documented repeatedly (Adler, Kreeger, & Ziegler, 1983; Conn & Lion, 1983; Inno, 1983; Lanza, 1988; Tardiff, 1983) in the past. The issue is also very contemporary, as the popular media, newspapers, television, and radio news are peppered with accounts of violent episodes in psychiatric settings. In a review of violence by psychiatric inpatients, Davis (1991) states that the literature provides some evidence that rates of violence may be increasing. Further, the author indicates that rates may be higher in the United States than in other nations. Individual factors related to violence identified by Davis include acute illness, psychosis, drug abuse, age, and history of violence. Situational variables identified by this author include overcrowding, provocation, staff inexperience, and management tolerance of violence. In addition, Davis identifies structural factors associated with violence, including changes in mental health policies, that have made dangerousness and a shortage of treatment resources a frequent criterion for commitment. The author concludes that violence in psychiatric settings is the result of an interaction between the various types of factors and is not simply an expression of individual pathology.
In a study conducted in a "regional secure hospital" in London, England, Rix and Seymour (1988) found that, during a one-year period, the majority of incidents were minor in nature with a few assaults that involved pain, lacerations, or bruising. The staff at the bottom of the nursing hierarchy who spent the most time with patients were found to be most at risk. Other patients were often involved in the incidents. A replication study of staff injuries in state hospitals by Hanson and Balk (1992) confirmed the prior findings of Haller and Deluty (1988) that nursing staff received the majority of injuries, with a higher rate of injuries among male staff than among female staff.
Contributing Factors - Several studies have focused on factors that contribute to aggression in psychiatric settings. Morrison (1990) explored the components of nursing care that may influence the amount of violence occurring in inpatient psychiatric settings, specifically the characteristics of violent patients and the components of nursing care that are related to violent patient behavior. This qualitative study used participant observation and grounded theory methodology to reveal six categories of violent patients: the user, the outlaw, the rebel without a cause, the little big man, the child, and the vamp. The author draws implications from the findings for dealing with patient behaviors. In a later study, Morrison (1992a) developed and tested a causal model in which violence and aggression were hypothesized to be predicted by a coercive interpersonal style and negatively predicted by an accommodating interpersonal style. The results of the theoretical model testing suggested that 60% of the variance in aggression was explained by four model variables: intimidation and interpersonal control (coercion), length of hospitalization, history of violence, and bipolar affective syndrome. The author again derived implications for clinical care. In a synthesis of the results of her research and the research of others on violence, Morrison (1994) calls for new interventions that take into account the social interactive nature of violence.
Management - Canili, Stuart, Laraia, and Arana (1991) offer guidelines in the management of potentially violent psychiatric inpatients. They suggest that key factors are slrillful observation of patients' motor behavior, verbal clues, and change in mental status; use of prevention strategies; and acute crisis intervention techniques with the organization and execution of a plan of immediate action. They further suggest that psychiatric nurses must be able to work well under stress and be able to organize and execute a plan of immediate action. In addition, they define the final intervention as assisting patients to manage their own behavior and supporting their newly acquired skills.
Effects On Staff - The multiple articles regarding the effects of violence on staff and resources and approaches for dealing with the fallout produced by violence on psychiatric units are indicative of the magnitude of the problem. Morrison (1992b) and Herzog (1992) discuss therapeutic and protective measures, as well as legal actions that staff can take when they are attacked by patients. Murray arid Snyder (1991) describe a nursing consultation support service offering a supportive, non-blaming response to the assaulted staff victim. Their results suggest that their combined quality assurance and consultation approaches have worked to increase information on assault incidents and to provide support for staff assault victims. In a study of post-traumatic stress disorder in staff victims, Caldwell (1992) found that 86% of non-clinical staff who experienced traumatic events reported later symptoms, while all but one of 138 clinicians who had such experiences reported symptoms. Caldwell concludes that one of the most hazardous work settings for employee mental health may be the local mental health facility. A peer support program for staff who have been assaulted by patients is described by Dawson, Johnston, Kehiayan, Kyaoko, and Martinez (1988). The program was initiated in response to concern about staff turnover. There was a definite decrease in staff turnover, but it was not possible to isolate the program as the only contributing factor. Additional benefits include an increased centered awareness of the concept of role conflict post-assault and the benefit of specific intervention in working toward successful resolution. Morrison (1987/1988), in a discussion of healing strategies for assaulted staff, identifies the following consequences of implementing a comprehensive approach to assist nurses to cope with the assault: a) an increase in mobilization of resources within the system; b) less disruption within the patient group; c) accurate reporting of assaults; d) increased retention of staff; and e) the movement of nurses toward the goal of increased professionalization.
In a preliminary study to investigate the strain and social support experienced by nurses after being assaulted by a patient, Whittington and Wykes (1992) found that assaults resulting in no apparent physical injury caused a severe response in a few of the assaulted nurses. In addition, the victims received support only on an informal basis concentrated in the 24 hours following the incident. Because symptoms persisted in some people for at least 2 ½ weeks, the need for support is much longer. A qualitative study of 12 nurses who had been assaulted revealed strong responses to the assault, anger being the most frequent, as well as long-term consequences (Roberts, 1991). The experiences of these nurses were significantly similar to women's experiences with violence in general. The nurses were outraged by their institutions' apparent tacit acceptance of the inevitability of violence as a part of the job. The author concludes that hospital policies must state that employees must be provided with the services appropriate to any victim of violence, including medical care, legal advice, information on workers' compensation, counseling, and peer support programs.
Costs - A study of the cost of injuries from inpatient violence in an all male forensic state hospital suggested that: a) injuries resulting from battery (typically head injuries) were more costly than containment injuries (typically damage to the trunk or extremities) and required more time off and restricted duty; b) injuries to female employees, especially from battery, were more costly than injuries to male employees; c) a major portion of workers' compensation costs went to a small number of employees who litigated their cases and did not return to work (Hunter & Carmel, 1992). The authors conclude that in an era of cost containment and risk management, it is critical to develop accurate loss analysis of employee injuries from patient violence.
Defining Injury - It must be noted that definitions of injury to staff from patient assault vary throughout the literature and from institution to institution. The standard used in reporting employee injuries to the Occupational Safety and Health Administration (OSHA) includes injuries resulting in lost work days, loss of consciousness, restriction of work or motion, termination of employment, transfer to another job, or medical treatment (other than first aid). It is clear, based on the literature review, that the OSHA standard excludes many of the sequelae of assault suffered by nursing staff.
Incidence - The occurrence of violent and assaultive behavior continues to increase in hospital settings and in emergency departments. Ajournai that focuses on health care protection management ("Crime," 1991) reported that assaults increased from 1,435 in 1988 to 1,789 in 1989. In 1989, 49% of assaults took place in emergency departments (EDs) and 23% in psychiatric settings. A 1989 survey by the International Association for Hospital Safety and Security documented incidents including sexual assault, arson, battery, armed robbery, kidnapping, homicide, suicide, theft, and bomb threats.
California's Emergency Nurses' Association (ENA) Government Affairs Committee conducted a survey to determine: a) the magnitude of violence against nurses, b) current practices in an effort to deal with aggressive or violent behavior, and c) current security practices within institutions (Keep, Gilbert, & the California ENA Government Affairs Committee, 1992). Members of the committee agreed that if a problem was found, the California ENA would draft and sponsor legislation to curb violence against ED staff. One-hundred-three nurse managers from five metropolitan areas responded that EDs without nearby gang or drug activity experienced considerable violence. Although many incidents included verbal and physical threats without weapons, actual acts of violence were occurring, most with minor injuries resulting in several days off work. The nurse managers reported the ED employees lack training in recognizing and dealing with dangerous individuals. Over half the EDs surveyed reported incidents involving weapons brought in by patients or visitors, most commonly knives and loaded guns.
Goetz, Bloom, Chenell, and Moorhead (1991) conducted a retrospective study of 500 patients who were searched for weapons by security officers in a university hospital ED over a 20-month period. It was found that 17.3% of psychiatric patients and 15.7% of medical patients searched were carrying weapons.
Mahoney (1991) studied the extent and nature of victimization of emergency nurses in acute care hospitals in Pennsylvania. Responses from 124 rural, suburban, and urban hospitals indicated that alcohol was involved in over one-half of victimizations. Emergency Department nurses were more likely to be victimized during evening and night shifts, with those who worked 12-hour shifts found to be at greater risk. Over one-half of the individuals reported they had no instruction regarding victimization.
Contributing Factors - The Emergency Nurses' Association position statement identifies factors that contribute to violence in emergency departments: long waiting periods, staff shortages, ED overcrowding, availability of drags and hostages, access to the rest of the hospital through the ED, and use of ED for psychiatric and medical clearance of patients with alcohol and drug abuse (ENA 1991). Pane, Winiarski and Salness (1991) add the increase in gang violence and the lack of necessary outpatient psychiatric care facilities as contributing factors.
Mahoney (1991) noted that the ED offers 24-hour-aday accessibility and that the physical environment of the ED is noisy and full of activity that can be conducive to unrest. Not only are increasing numbers of individuals using EDs as sources of primary care (Friedman, 1992), but more ED patients and families seem to be angry, and more quickly upset and frustrated. Medical conditions associated with victimization of nurses include insulin reactions, cerebral trauma, and Alzheimer's disease (Mahoney, 1991).
Management - Provisions of the bill developed by the California ENA resulted in legislation that addresses the following: educating and training personnel; establishing a reporting mechanism for violent incidents; conducting a security and safety assessment; and developing a security plan to protect personnel, patients, and visitors from violent behavior (Stonis, 1994).
A special report published in Hospital Security and Safety Management ("Emergency room," 1989) suggested approaches for increasing the safety in EDs. These included implementing greater access control and visibility of all entrances, the use of security measures such as metal detectors, silent alarm systems, closed-circuit televisions, the maintenance of dedicated rooms for seclusion and treatment of psychiatric or potentially violent patients, implementation of strategies to ease the stress of waiting time, and careful assignment of personnel to the ED.
Several authors offer suggestions for preventing and/or managing potentially violent situations. Gull (1992) suggests the need to include security with information regarding intoxicated or combative patients, calling for security assistance early, and involving security personnel in training and maintaining communication between departments.
Kurlowicz (1990) states that patients who show increased tension should be watched for potential violence. Indicators include history of violence, shouting, paranoid or delusional statements, increased psychomotor activity, body language such as tight grip, overall tautness, violent gestures, or intensified facial expressions, disheveled or bizarre physical appearance, and diagnoses frequently associated with violent behavior, such as alcohol or drug intoxication and those presenting with psychotic manifestations.
Interventions may be verbal, pharmacologic, or environmental. Talking with, supporting and reassuring the patient, while asking those with a stabilizing influence to stay, and others to wait away from the patient may prevent the escalation of a potentially violent situation. Limits may be set by returning the patient to a quiet room and offering a cold drink with medication. Pharmacologic and external restraints should be judiciously used after careful assessment.
Glasson (1991) suggests that each ED monitor the types of injuries of patients who use the facility in order to determine risks or vulnerabilities. What impact do these patients have on ED staff? What training is indicated to ensure knowledgeable and safe practice by ED personnel? It is of utmost importance that each ED have procedures for dealing with violent or disruptive behavior.
Effects on Staff- Mahoney (1991) reported that four of Lanza's (1983) biophysiologic responses were most frequently cited a» problematic for staff who were assaulted: body tension, headache, difficulty falling asleep, and body soreness. Emotional responses included anger, anxiousne8S, helplessness, loss of control, and increased irritability. Social responses included fear of the perpetrator and changes in relationships with co-workers. Sixty percent reported that Nictimization adversely affected their job performance for several days to a week. Twenty percent considered leaving nursing and 16.9% considered requesting a transfer to another area of the hospital as a result of that experience.
Costa - True financial costs of rictimization have yet to be calculated. Responses from ED nurses to both formal and informal surveys indicate that the emotional and physical tolls are great (Glasson, 1991). Certainly, situations resulting in loss of life are immeasurably costly.
Defining Injury- The terms verbal abuse and victimization are not consistently defined in the emergency nursing literature. Parsonage and Miller (1990) defined verbal abuse and victimization as any violence, threat of violence, mtimidafion, extortion, theft of property, damage to one's reputation, or other act that inflicts damage, instills fear, or threatens one's sensibilities. This definition serves as a basis for the work of Mahoney as well (1991).
Long-Term Care Settings
Incidence - Lusk (1992) conducted an exploratory study to explore psychosocial and ergonomie stressors for nurses' aides in seven midwestern nursing homes. Data were obtained through interviews with directors of nursing, focus group meetings of nurses' aides, and observations of workers. In the interviews with the seven directors of nursing, two indicated that physical abuse from patients is a physical problem/ergonomic stressor for nurses' aides, and three indicated that abuse from patients was a psychosocial stressor for nurses' aides. In all seven of the focus groups, physical abuse was listed as a physical problem/ergonomic etressor. Three groups identified verbal and physical abuse as psychosocial stressors. During a limited 2-hour observation of workers in longterm care settings, numerous violent/aggressive behaviors were noted.
Home Care Providers
Increased numbers of weapons, drug dealing, and violence throughout the city led the Hartford branch office of the Visiting Nurse and Home Care (VNAHC) to develop an escort/security program that would provide staff protection against the dangers of the urban environment and allow the nurses to provide care for inner city residents (Nadwairski, 1992). The Hartford branch of the VNAHC has a formal security program that consists of a full-time security supervisor and 18 escorts. The agency has implemented training, education, follow-up, the development of community relationships, and ongoing community assessment to ensure employees' safety.
Across the country, 30 public health nurses in western Washington were interviewed to determine how they knew that they had improved their clients' lives. Although they believed that they were able to make a difference, their comments revealed that clients' substance abuse and violence were very threatening to the nurses' own physical and emotional well-being (Zerwekh, 1991).
In a discussion of violence and home care nurses, Fisher (1994) describes an educational prevention program implemented by ABC Home Health Services in Pittsburgh, Pennsylvania. This program teaches nurses to be more aware of potential danger, to use techniques for prevention of potential problems, and bow to deal with a potential assailant. The author concludes that while these techniques may be effective in some cases, more may be needed. In some home care settings, contracted guards, off-duty police officers, state troopers, and housing authority agents may be needed to escort nurses.
Based on the multitude of documentation of increasing violence in health care settings, nursing students must be prepared to deal with this issue, both as students and as practicing nurses. Basic preparation of students for dealing with aggressive clients will be discussed within the context of the nursing process.
Student Responses to Specific Situations
Strategies for Nursing Education
Nurse educators can help students prepare to deal with the possibility of aggression in health care settings. This involves educating students in assessment, planning, and interventions to prevent or intervene with aggressive behaviors from clients, families, visitors, or others. A variety of strategies can be used in conjunction with specific content to prepare students for the experiences they will encounter (Table 1).
Self-Awareness - The first step is educating students in self-awareness. Students' nonverbal and verbal behaviors may unwittingly send the wrong message to persons with escalating behavior. For example, students may raise their voices, use authoritarian messages, and step closer to the escalating individual. The more therapeutic response would be to speak softly, use non-threatening comments, and actually step back from the individual. Videotaping students during role play situations is an excellent tool in assisting them to critically examine their own communication styles and in addressing positive and negative messages they may be sending. For example, students can work with a partner and take turns being the nurse and the patient or family member. They then practice responses to given situations such as refusing to take medication, confusion over visiting hours, disappointment with hospital care, and other pertinent scenarios (Table 2).
Values Clarification Exercise
An attitude of "unconditional positive regard" is necessary to gain the trust and cooperation of cuente. Class or small group discussions about values, expectations, and fears surrounding clinical experiences will assist students in identifying areas of value conflict and development of respect for clients. Values clarification exercises are a stimulating way to get these discussions underway. Typical values exercises include making choices about what types of persons and behaviors students would "value" and are useful in helping the students identify persons who may generate feelings of conflict or discomfort in the students (Table 3).
Assessment and Diagnosis - Students can then learn to use the nursing process as a tool for approaching aggressive incidents. Initial assessment skills taught may concentrate on the environment. In any setting, students can become environmentally aware or "scan" for liabilities and assets in the area. A quick environmental survey may assist them in developing this skill (Table 4). For example, many exits from an area are an asset and multiple types of medical equipment in a small space are a liability. What then is the relationship of these objects to the students? Studente can learn that they should be near an exit with the escalating client further away. Tables or bedside stands can provide barriers but can become a weapon or can also be a hindrance if the student is on the wrong side. Having students actively increase their awareness of the "mental status" of a milieu, effects of overcrowding, and staff availability are other key points to evaluate when "scanning" the environment. Students can practice this skill in a variety of health care or even social settings and discuss observations with peers and faculty making them increasingly attuned to their environment (Ruscitti, 1992).
The next learning experiences focus on listening and using observational skills to assess clients. Characteristics associated with aggressive behaviors should be clearly identified (Kurlowicz, 1990). It is helpful to role play many of these obvious aggressive behaviors including speaking in loud voices, verbalizing in a demanding manner, clenching fists, and taking steps toward the student. Other behaviors may indicate lack of impulse control such as grabbing, slamming or hitting objects, inability to tolerate delays in treatments or requests, confusion or disorientation which often leads to suspiciousness, and motor agitation such as paring and restlessness. Escalating or abrupt changes in a client's behavior or other changes in a client's mental status may also be indicative of possible aggressive behavior. Having students assess and document client's responses to visitors, or family responses to staff interactions may increase the student's awareness of behavioral changes in the milieu.
Planning - Planning, particularly prevention, should be the focus in assisting students in anticipating thenresponses to aggression. Student awareness, education, and readiness may enable earlier and more beneficial interventions. Faculty and students should clearly identify their role in handling aggressive incidents before they occur. Orientation to health care facilities should include a frank and practical discussion about how aggression is dealt with in the agency (Oakley, 1991).
Intervention - Useful interventions include identifying and reporting aggressive characteristics and comments of clients, getting staff assistance early, and knowing the procedure for calling in more help. Through role play, students can practice techniques to intervene with patients whose behavior and emotions are escalating. Using techniques such as personal space concepts, nonaggressive stance and statements, control of voice tone and volume, and honesty of responses can be practiced. It is prudent, however, to allow more experienced staff to intervene in actual clinical situations and give students back-up tasks such as calling in resources, clearing space, removing others from the area, and caring for patients in the setting who may be frightened or otherwise affected by the incident. An important concept in aggression management is that one person should be in charge of the immediate situation and only that person should direct communications toward the escalating client.
Evaluation - After any aggressive or even near aggressive incident, it is essential for students and faculty to evaluate events leading up to the episode, interventions that occurred, and possible alternatives. Student physiological and psychological responses can be explored and support given to involved individuals. Necessary documentation may vary within each institution and may be dependent on mental health laws within the state in the case of psychiatric patients. The student should be made aware of documents that are completed, as well as the rationale for each. Debriefing sessions may need to be carried out for more than one session so that discussion can take place after students have had an opportunity to think critically about the situation when immediate feelings of anxiety or fear have subsided.
Long-Term Treatment Goals - Students also need to be aware that overall treatment strategies need to be implemented that assist patients in eliminating violent behaviors and in gaining more control over their lives. Morrison (1993) emphasizes the importance of removing rewards for violence and planning care that allows and encourages patienta to assume more control, thus decreasing the likelihood of using violence to gain control. Her second protocol for care is to teach patients to talk directly about their anger with those involved. Facilitating appropriate expression of anger and assisting in conflict resolution is a more effective intervention than the traditional general discussion of feelings which reinforces the anger and increases the likelihood of further aggression. Further, Morrison emphasizes the need for consistent, fair limit setting, as well as for the communication of a clear expectation that violence is unacceptable.
In an editorial on violence in health care, CarrollJohnson (1993) emphasizes the increasing incidence of violence and points out that nurses, as compassionate caregivers, may find ways to excuse patient and family violence rather than insisting on their own personal safety and polite treatment. She goes on to recommend that violence prevention be incorporated into undergraduate nursing curricula and that nurses, both new and seasoned, be socialized to the idea that nurses' personal safety needs have priority too. She points out that nurses' safety is as important as that of the people they serve. We are morally and ethically obliged to provide this orientation to our nursing students.
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Student Responses to Specific Situations
Values Clarification Exercise