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The epidemic of violence against healthcare workers
  1. D M Gates
  1. Correspondence to:
 Dr D M Gates
 College of Nursing, University of Cincinnati Medical Center, 212 Procter Hall ML 0038, 3110 Vine Street, Cincinnati 45221-0038, USA;

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No longer silent

Staggering rates of verbal and physical violence are documented in the study by Gerberich and colleagues,1 published in the June issue of OEM, and yet most nurses and other healthcare workers state that the problem highlighted by this research is not new. Although many healthcare workers believe that workplace violence is increasing, there is a paucity of existing evidence to support these claims due to low reporting rates. Gerberich and colleaguess’ 15% report rate for physical assaults against nurses supports other studies that also found low rates.2,3 Compared to physical assaults, non-physical violence is documented even less, although researches such as Gerberich et al found that the negative consequences associated with such violence are substantial. When healthcare workers are asked why they don’t report violence they most commonly state that the incident is not associated with injury or lost work, reporting is too time consuming, reporting lacks supervisory support, and reporting won’t make any difference. Most incredible, nurses indicate that violence is to be expected. In the Gerberich et al study, 44% of nurses do not report physical violence because it is just “part of the job”. An additional alarming finding from this study is that only 27% of the nurses perceive violence to be a problem in their workplace, even though 13% experienced physical assaults and 38% experienced non-physical violence during the previous year. Unfortunately, these findings suggest that violence may not be identified as a problem until there is a critical incident with casualties.

So what are the reasons for the recent attention to the problem and why are these recent studies that document the magnitude of the problem, such as one by Gerberich and colleagues1 so important? The answer to these questions involves consideration of several complex issues.

First, experts believe that the risk of verbal and physical violence is increasing across diverse types of healthcare settings. For example the most assaulted US worker is the nurse aide working in a nursing home and the perpetrator is most often an elderly patient, often with dementia. Fifty nine per cent of nurse aides report being assaulted once a week and 16% report that they are assaulted daily.3 The number of elderly in long term care and other healthcare settings will increase dramatically as the US population ages. In addition to nursing home employees, emergency department (ED) workers also voice increasing concern about violence from patients and visitors and many report that they seldom or never feel safe at work.4 These workers believe that the escalating risk in their environments is due to increased drug and alcohol use by patients and visitors, presence of weapons, poor patient and visitor coping skills, long wait times, and the increasing number of patients with dementia and psychosis. There is mounting concern that the heightened level of community violence is being brought into and mirrored in the ED, a common entry into the healthcare setting. And for community workers, whereas in the past many wore uniforms and other forms of identification to increase their safety, today many home health workers state they feel safer without identification that targets them for perpetrators looking for money, drugs, or drug paraphernalia.5 When patients and visitors use healthcare services it is often with feelings of anxiety, frustration, and loss of control; they frequently encounter long waiting lines, high medical costs, fragmented services, and understaffed and frustrated workers. Several US states have concealed weapon laws; persons in our communities are carrying guns in their pockets, purses, and briefcases, making them too easily available when tensions are high. Healthcare settings today are places where everyday encounters between patients, visitors, and staff could easily evolve into a threatening situation.

Second, recent media attention to school and workplace shootings raised the level of civic consciousness regarding the adverse effects of violence. Most Americans know that the phrase “going postal” indicates an employee who becomes hostile at work. However the public focus is on occupational environments that are exclusive of healthcare sites. As the media remains instrumental in drawing attention towards violence in selected settings, OSHA concurrently influences safety by writing violence prevention guidelines for high risk workplaces, including healthcare. However, despite the collective impact of the OSHA guidelines6 and the media, Gerberich and colleagues1 and other researchers find that the rates of violence for healthcare workers remain high and prevention efforts low. Studies as those by Gerberich et al emphasise the need for further research to examine workplace violence explicit to the healthcare industry.

Third, healthcare workers’ experiences with non-physical and physical violence are being increasingly recognised for their association with decreased job satisfaction, increased occupational strain, and poor patient care outcomes.7 Gerberich and colleagues1 found that adverse consequences of violence (for example, turnover) are common and interestingly more prevalent with non-physical than physical violence. An alarming finding is that much of the violence encountered by healthcare workers is from co-workers and managers. Gerberich and colleagues1 found that 33% of non-physical violence experienced by nurses was perpetrated by visitors, co-workers, physicians, and managers. Nurses recently told me that administration’s response to their complaints of frequent verbal and physical sexual harassment by a physician was that the violence must be tolerated because that individual brings substantial dollars into the hospital system. Similarly, nurse aides report that violent visitors (relatives) are tolerated in nursing homes because of the administration’s financial pressure to keep beds filled. Such violence would not be tolerated at other workplaces; employees’ contracts of employment would be terminated and visitors refused access. Violence in healthcare settings needs to be similarly dealt with so that these environments will become safer, more civil, and desirable places to work. The serious shortage of healthcare workers will not improve until the workplace culture is administratively addressed.

Fourth, as studies such as the one published by Gerberich and colleagues1 become more widely circulated, perhaps a larger cadre of healthcare workers will recognise violence as a problem and refuse to accept violence as “part of the job”. The difficulty in dealing with violence often stems from the realisation that violence from patients cannot be totally eliminated as there will always be non-intentional verbal and physical assaults from patients with diseases, such as dementia or psychosis. In order to cope with this type of inherent violence, workers need supportive environments that promote employee, administrative, and organisational awareness that violence is often traumatic. During a recent conversation I had with an ED manager she described to me how one of her nurses was punched in the face by a patient. She continued to describe how the nurse’s co-worker told her “maybe she could have prevented it” and “to get over it; is not a big deal”. Blaming the victim is a common and unacceptable approach. As research into violence continues, healthcare workers will hopefully demand that their employers do more to protect them from violent patients, visitors, and co-workers. Use of OSHA’s guidelines for engineering controls, work practices, training, and policies will help to decrease the violence. In turn, employees need to be encouraged to document violence so that successful prevention and management efforts can be implemented.6

In conclusion, if agreed that all violence against healthcare workers is not likely to be eliminated, the questions remains: What kind and how much violence should be tolerated? To what degree are healthcare facilities expected to act to protect workers from violence? OSHA’s General Duty law states that employers are liable if they know workers are at risk of harm and do not take action to decrease the workers’ risk. The majority of healthcare workers are at risk for violence and healthcare employers need to do more. Period.

No longer silent