Risk Factors Associated With Workplace Violence
Staff, environmental, and patient risk factors are the major precursors associated with workplace violence incidents initiated by patients (Taylor & Rew, 2011). Taylor and Rew (2011) conducted a systematic review using MEDLINE, CINAHL, and PsycINFO databases to obtain journal articles as well as dissertations and theses from full text databases. A total of 16 articles were used and included qualitative and quantitative studies testing an intervention. A limitation of their review was the specific articles used pertained solely to the emergency department. Poor security, delays in service, and working closely with potentially dangerous individuals were found to be the most common environmental risk factors. Patient risk factors included access to guns and substance abuse. Staff risk factors included inadequate or nonexistent training on the management of assaultive behaviors, understaffing, and working alone (Taylor & Rew, 2011).
Nurses' Perceptions of Workplace Violence
Many nurses often view workplace violence as part of the job (Child & Mentes, 2010). In some instances, when nurses work in settings where violent incidents occur frequently, a culture of acceptance of violence persists (Wolf et al., 2014). Blando, O'Hagan, Casteel, Nocera, and Peek-Asa (2013 evaluated whether nurses' perceptions of violence and safety were influenced by their work environments and also identified whether their perceptions were correlated with actual risk. The study was a cross-sectional survey that was administered to 314 emergency department and 143 psychiatric nurses working in various hospitals in California and New Jersey. In addition, incidence of workplace violence, response of security guards, and appropriate training were found to play a role in nurses' perceptions of violence and safety in the workplace. The authors noted that perceptions of violence vary among nurses, and they are affected by existing conditions in the workplace. Differences between emergency department and psychiatric nurses were significant. Emergency department nurses were more likely to report feeling unsafe and more threatened when they were verbally assaulted compared to psychiatric nurses. Moreover, psychiatric nurses were more tolerant of abusive behavior and had more training in de-escalation practices. Furthermore, Blando et al. (2013) used a univariate logistic regression statistical analysis to identify the major variables that measured the outcome of the emergency department nurses' perceptions of safety. A multivariate logistic regression was further performed on those variables showing that response time by security personnel, appropriate security equipment, and frequent verbal abuse were significant in the emergency department nurses' perceptions of safety. The researchers reported that nurses' perceptions of violence and safety may not correlate with the actual risk, as statistical analyses showed differences between the perceptions and actual rates of assault that occurred in the emergency department (Blando et al., 2013).
Interventions to Reduce Workplace Violence
Dilman (2015) presented the use of a code green response team (CGRT) as an evidence-based intervention implemented in 2013 in a Pennsylvania hospital. The CGRT comprised a charge nurse, security personnel, and the physician and primary nurse managing the potentially violent situation. The major functions of the CGRT included using the least restrictive measures, such as verbal de-escalation skills and noncoercive use of medications, to control violent or escalating situations. Data were collected for 1 year using a post-violence debriefing tool and an incident report form to measure the rates of restraints applications and de-escalation of potentially violent patients. The results demonstrated that 85% of code green calls resulted in successful resolution of the violent incidents using verbal de-escalation skills and noncoercive medication administration, and a decrease of restraints application in nursing units by 11% compared with restraint data obtained in 2012. The effectiveness of the evidence-based intervention showed a reduction of patient restraints and effective management of aggression using least restrictive measures in a hospital (Dilman, 2015).
Hill, Lind, Tucker, Nelly, and Daraiseh (2015) implemented a quality improvement initiative in an Ohio hospital to decrease staff injuries in an inpatient psychiatric unit specialized in treating children and adolescents with developmental disabilities and other co-occurring psychiatric disorders. Hill et al. (2015) employed the Plan, Do, Study, Act (PDSA) rapid interventions testing process to investigate the interventions and continue decision making. Occupational Safety and Health Administration (OSHA) reportable injury standards were used to record the types of injuries that occurred in the unit during the initiative. A major intervention used was the creation and implementation of universal precautions posted in the unit for clinical staff members, including nurses and unlicensed personnel. Universal precautions included the following: be aware that patients have the potential to strike-out; wear appropriate clothing; rearrange environments in the setting to minimize the risk of injury with objects during crisis; maintain appropriate positioning when approaching patients; keep a safe distance; sustain the proper stance (i.e., show one third of the body when working with patients); use protective personal equipment, such as gloves and forearm and knee pads; and learn and use de-escalation techniques and active listening (Hill et al., 2015).
Moreover, other interventions used included standardized team meetings to increase awareness of potentially violent patients and plan for crisis; bedside handoff to review patients' problematic behaviors and approaches taken; patient information binders and boards identifying high-risk behaviors; critical incident reviews; leadership rounds conducted by directors of nursing, psychologists, quality managers, and other supportive members to assess the interventions used by staff; proper use of protective personal equipment; and conducting risk identification (Hill et al., 2015). The quality improvement initiative showed a 65% reduction of staff injuries, from 2.2 per week to 0.77 per week, during the 1-year intervention period. In addition, the days in between occurrences of OSHA-reportable injuries increased from 26.5 days to 124 days (Hill et al., 2015).
Lanza, Rierdan, Forester, and Zeiss (2009) conducted a pilot study to assess the efficacy of a violence prevention community meeting (VPCM) in decreasing the prevalence of workplace violence in an acute in-patient psychiatric setting. The major intervention of the VPCM was a 30-minute meeting that focused on violence prevention topics in psychiatric settings, which was conducted twice per week by nursing staff during the day shift and attended by patients.
During the 9-week pilot study, nursing staff led community meetings in the inpatient psychiatric unit, encompassing a number of topics to prevent workplace violence, including, but not limited to: establishing unit rules, importance of safety in the unit, what to do if losing control, modeling problem solving, discussions of violence reduction, discussions of reactions regarding assaults, and discussion of accepted alternatives to violence (Lanza et al., 2009). Nursing staff adjusted the topics discussed during the meetings according to the acuity in the unit. The recording of workplace violence events in the unit was conducted by nurses and researchers in real time during the course of the study. The VPCM program was effective, reducing incidents of violence by 85% among all shifts throughout the duration of the study. The study presented a validated evidence-based intervention with promising results to manage workplace violence that can be implemented in inpatient psychiatric settings (Lanza et al., 2009).
Anderson, FitzGerald, and Luck (2010) conducted a literature review to evaluate interventions aimed at decreasing violence against emergency department nurses. The authors used MEDLINE, CINAHL, and the Cochrane Library to conduct their literature research. The authors cited the study by Meyer, Wrenn, Wright, Glaser, and Slovis (1997) that implemented the use of a metal detector under the continuous surveillance of a security guard as a major intervention addressing environmental risk factors in the emergency department (Anderson et al., 2010). The study by Meyer et al. (1997) evaluated the patrons' and emergency department nurses' perceptions regarding the use of a metal detector in this setting. The study results showed that 80% of patrons and 85% of employees liked the idea of having a metal detector in the emergency department; 90% of patrons and 73% of employees felt safer (Meyer et al., 1997). The study presented an intervention that was implemented in one emergency department, which can be implemented in other emergency departments and nursing units.
Gillespie, Gates, and Mentzel (2012) conducted a quasi-experimental study to evaluate the effectiveness of delivering an educational program on workplace violence for 315 nurses using web-based and classroom-/web-based hybrid programs. The study results showed that the classroom-based program may have a positive effect on the information being taught when used in conjunction with a web-based program to enhance knowledge attainment among nurses (Gillespie et al., 2012).
Negative Consequences of Workplace Violence Against Nurses
Nurses often experience psychological and physical effects after an incident of workplace violence, which may impact their careers and personal lives. Edward et al. (2014) conducted a systematic review about workplace violence against nurses to understand the types of aggression, effects on nurses, and coping strategies used by nurses. The authors used MEDLINE, CINAHL, and PsycINFO databases to conduct their literature search. They found that nurses who encountered aggression in the workplace may experience anger, frustration, feelings of hopelessness, hyper-vigilance, post-traumatic stress disorder, develop depression or anxiety, and even leave the nursing profession (Edward et al., 2014). Taylor and Rew (2011) noted that physical assaults may cause fatal and nonfatal injuries and reduce nurses' ability to perform job requirements.