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Workplace Violence
Elizabeth Boldon, RN, MSN
Elizabeth Boldon is a Nurse Education
Specialist at Mayo Clinic in Rochester,
Minnesota. She received a BSN from Allen
College in Waterloo, Iowa in 2002 and an
MSN with a focus in education from the
University of Phoenix in 2008. She has
bedside nursing experience in medical
neurology and the neuroscience ICU.
ABSTRACT
Workplace violence is a complex and widespread issue that has received
increased attention from the public, mental health experts, law enforcement,
and healthcare professionals. A recent increase in workplace violence has
been reported. Workplace violence in healthcare can include violence from
the patient, relatives and friends of patients. Pain, anxiety, loss of control,
powerlessness, and disorientation may result in aggressive incidents against
nurses. Violence in Emergency Departments may result due to varied
reasons, including access to weapons and crowded and emotional situations
occurring in emergency settings. Some healthcare organizations have
implemented a “code” for violence that evokes a rapid response. The
incidence of occurrences, type of violent incidents and prevention of violence
are discussed.
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Continuing Nursing Education Course Planners
William A. Cook, PhD, Director, Douglas Lawrence, MA, Webmaster,
Susan DePasquale, MSN, FPMHNP-BC, Lead Nurse Planner
Policy Statement
This activity has been planned and implemented in accordance with the
policies of NurseCe4Less.com and the continuing nursing education
requirements of the American Nurses Credentialing Center's Commission on
Accreditation for registered nurses. It is the policy of NurseCe4Less.com to
ensure objectivity, transparency, and best practice in clinical education for
all continuing nursing education (CNE) activities.
Continuing Education Credit Designation
This educational activity is credited for 3 hours. Nurses may only claim credit
commensurate with the credit awarded for completion of this course activity.
Statement of Learning Need
Workplace violence in healthcare can take many forms. It is a widespread
and complex issue. Healthcare workers need to be informed and
appropriately trained to recognize warning signs and to act to prevent harm
to self, co-workers and others, including harm to patients during the delivery
of healthcare.
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Course Purpose
To provide nurses with knowledge on how to recognize and understand the
implications of workplace violence upon the nurse and the health
environment, and of available resources to report violence and to seek help.
Target Audience
Advanced Practice Registered Nurses and Registered Nurses
(Interdisciplinary Health Team Members, including Vocational Nurses and
Medical Assistants may obtain a Certificate of Completion)
Course Author & Planning Team Conflict of Interest Disclosures
Elizabeth Boldon, RN, MSN, William S. Cook, PhD, Douglas Lawrence, MA
Susan DePasquale, MSN, FPMHNP-BC - all have no disclosures
Acknowledgement of Commercial Support
There is no commercial support for this course.
Activity Review Information
Reviewed by Susan DePasquale, MSN, FPMHNP-BC
Release Date: 3/15/2016
Termination Date: 3/15/2019
Please take time to complete a self-assessment of knowledge, on page 4,
sample questions before reading the article.
Opportunity to complete a self-assessment of knowledge learned will be
provided at the end of the course.
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1. ______ % of all nonfatal injuries from occupational assaults
and violent acts occur in healthcare and social service settings.
a. 25 %
b. 48 %
c. 15 %
d. 33 %
2. True of False. Workplace Type I incidents involve offenders in a
relationship with either the victim or the establishments.
a. True
b. False
3. Healthcare workers are at increased risk for workplace violence
due to multiple factors, including:
a. prevalence of handguns/weapons among patients and the public
b. use of hospitals for holds on acutely disturbed, violent individuals
c. availability of drugs or money at health sites and pharmacies.
d. all of the above
4. True of False. A Workplace Violence Prevention Program
combined with training can reduce workplace violence.
a. True
b. False
5. An important aspect of a culture of safety is creating a:
a. violence-free work environment
b. work environment of mutual respect and dignity
c. fairness that nurtures teamwork and open communication
d. all of the above
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Introduction
Recent violent occurrences in healthcare areas have pushed the issue of
workplace violence to the forefront of the nursing community and other
agencies taxed with ensuring staff and patient safety. Nurses care for their
patients and envision making a difference in their patient’s health status,
decision-making abilities, and health outcomes.
Healthcare agencies, typically thought of as safe havens, now are facing a
significant increase in multidirectional acts of aggression from patients and
visitors. This course will discuss this important and growing issue, the
incidence of workplace violence, its consequences, and some strategies to
prevent and deal with occurrences of workplace violence.
Workplace violence, a complex and widespread issue, has received increased
attention from the public, mental health experts, law enforcement, and
healthcare professionals. According to a 2010 report from the Bureau of
Labor Statistics, 48% of all nonfatal injuries from occupational assaults and
violent acts occur in healthcare and social service settings. A recent increase
in workplace violence has been noted, causing a heightened awareness of
this issue among nurses.
What is Workplace Violence?
In September 2010, Baltimore city police and tactical team rushed to Johns
Hopkins Medical Center to subdue a gunman on the eighth floor of the
hospital. Patients, nurses, and other healthcare workers in the hospital and
vicinity were immediately evacuated when the alert was sounded. The
suspect became emotionally distraught after a surgeon updated him on the
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status of his mother’s grave condition. After hearing the news, the gunman
allegedly fired a semiautomatic handgun and shot the doctor in the
abdomen, seriously wounding him.
The case described above is tragic, but workplace violence is not a new
phenomenon. Workplace violence against nurses has been documented
historically since 1824.12 The wide range of acts that falls under the rubric of
workplace violence include all violent behavior and threats of violence, as
well as any conduct that can result in injury, damaged property, induce a
sense of fear, and otherwise interfere with the normal course of work.
Threats, harassment, intimidation, bullying, stalking, intimate partner
violence, physical or sexual assaults, and homicides fall within this category.
The World Health Organization (WHO) established guidelines to address
violence against workers and defined workplace violence as “incidents where
staff are abused, threatened or assaulted in circumstances related to their
work, including commuting to and from work, involving an explicit or implicit
challenge to their safety, wellbeing or health.”24 Many important topics were
identified by the WHO taskforce on workplace violence in the health sector,
which were meant to stimulate and guide future initiatives at the
international, national and local levels to prevent and treat individuals
exposed to various forms of violence at work.
Workplace violence includes intimidation, verbal or physical threats, physical
attack, property damage and sexual harassment. The major types of
workplace violence are described in the table below.
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Table 1 – Types of Violence
Type of Violence
Verbal
Description
Outbursts of yelling and screaming; use of an exaggerated or
angry tone of voice;
cursing; use of derogatory, foul,
condescending, or inappropriate language, or use of racial or
ethnic slurs. It is not always what is said but how it is said or
when and where a comment is made.
Nonverbal
Includes eye rolling, raising eyebrows, making a face, turning
away from
a person, or physically excluding someone.
Although these nonverbal behaviors are not spoken, they are
seen and felt as abusive.
Passive behaviors
The absence of an action rather than an overtly identifiable
action that directly affects communication between caregivers
and can include not answering pages or returning phone calls,
not
responding
deliberately
to
or
being
communicating
impatient
incomplete
with
questions,
information,
and
silence.
Passive-Aggressive
Behavior such as complaining about an individual to others;
Behaviors
gossiping;
badmouthing
the
organization,
colleagues,
or
physicians to patients or others; discrediting leaders; fostering
disregard of policies and procedures; and being unnecessarily
sarcastic or negative. This type of behavior negatively affects
the patient care culture by demoralizing staff members and
destroying team support.
Physical Abuse
Behavior such as fighting, hitting, spitting, pushing, shoving,
pinching, kicking, and throwing objects is easy to identify and
must be off-limits to everyone. This includes any unwanted or
hostile
physical
contact,
threatening
body
language
aggressive movements or gestures.
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or
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Sexual Harassment
Demonstrates a lack of respect for an individual through the
use of overtly friendly or sexual behavior, inappropriate
touching, unwelcome advances or invasion of personal space
with intent to intimidate, or verbal conduct of a sexual nature
(i.e., using vulgar or sexual language; telling off-color “dirty”
jokes or stories; referring to an individual’s body; describing
instruments or equipment in a sexual manner).
Employer/Manager
Issuing threats to report a person, making threats about the
Abuse
employee’s performance evaluation, berating staff members in
public or private, or denying an employee’s physical or
emotional response to an on the job injury. Employers and
managers have a responsibility to provide a safe workplace.
This involves being aware of and addressing the physical and
emotional safety of employees.
Workplace violence has been divided into four categories or acts based on
the relationship among victims, perpetrators and work settings.18 Type I
incidents involve offenders who have no relationship with either the victim or
the establishments. Type II incidents are those where the offenders
currently receive services from the facilities when they commit an act of
violence against them. Type III incidents involve those current or former
employees acting out toward their present or former places of employment.
In Type IV incidents, domestic disputes between an employee and the
perpetrator spill over into the workplace. Another type of workplace
violence, horizontal violence, is the violence that occurs among and between
workers and their colleagues and will be discussed later in this course.11
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Workplace violence in healthcare can take many forms. Violence from
relatives and friends of patients may occur as a result of frustration with a
perceived lack of care or communication. Pain, anxiety, loss of control,
powerlessness, and disorientation may result in aggressive incidents from
patients to nurses. Violence in Emergency Departments (EDs) may result
from the crowded and emotional situations that can occur with emergencies.
In addition, ED patients could be involved with crimes, weapons and violent
behaviors that could put the ED employee at an increased risk of workplace
violence. Some healthcare organizations have implemented a “code” for
violence that evokes a response like that of a rapid response team.
The U.S. Occupational Safety and Health Administration (OSHA) reports that
two million American workers report having been victims of workplace
violence each year; although, many more cases go unreported.22 Workplace
violence can strike anywhere, anytime, and no one is immune. Research has
identified factors that may increase the risk of violence for some workers at
certain worksites. Such factors include exchanging money with the public
and working with volatile, unstable people.
Working alone or in isolated areas may also contribute to the potential for
violence. Providing services and care, and working where alcohol is served
may also impact the likelihood of violence. Additionally, time of day and
location of work, such as working late at night or in areas with high crime
rates, are also risk factors that should be considered when addressing issues
of workplace violence. OSHA has identified those with higher risk are
workers who exchange money with the public, delivery drivers, healthcare
professionals, public service workers, customer service agents, law
enforcement personnel, and those who work alone or in small groups.22
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Healthcare workers, including nurses, are at particular increased risk for
workplace violence due to the following factors:

The prevalence of handguns and other weapons among patients, their
families or friends.

The increasing use of hospitals by police and the criminal justice
system for criminal holds and the care of acutely disturbed, violent
individuals.

The increasing number of acute and chronic, mentally ill patients being
released from hospitals without follow-up care (these patients have
the right to refuse medication and can no longer be hospitalized
involuntarily unless they pose an immediate threat to themselves or
others).

The availability of drugs or money at hospitals, clinics and pharmacies,
making them likely robbery targets.

Factors such as the unrestricted movement of the public in clinics and
hospitals and long waits in emergency or clinic areas that lead to client
frustration over an inability to obtain needed services promptly.

The increasing presence of gang members, drug or alcohol abusers,
trauma patients or distraught family members.

Low staffing levels during times of increased activity such as
mealtimes, visiting times and when staff transport patients.

Isolated work with clients during examinations or treatment.

Solo work (where a health worker functions alone), often in remote
locations with no backup or way to get assistance, such as
communication devices or alarm systems (this is particularly true in
high-crime settings).

Lack of staff training in recognizing and managing escalating hostile
and assaultive behavior.

Poorly lit parking areas.
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Incidence Of Workplace Violence
Violence isn’t just a problem for organizations in urban settings or highcrime communities. Incidents occur at community hospitals, and in
organizations in rural or medium-sized cities. According to a report by the
U.S. Bureau of Justice Statistics (BLS), an estimated 1.7 million workers are
injured each year due to assaults at work. In 2006, the BLS reported 60% of
workplace assaults occurred in healthcare, and patients had committed most
of the assaults.18 Healthcare support occupations had an injury rate of 20.4
per 10,000 workers due to assaults, and healthcare practitioners had a rate
of 6.1 per 10,000. Acute care hospitals account for almost one in 10 of all
workplace assaults that lead to lost workdays. As significant as these
numbers are, the actual number of incidents is much higher due to the gross
underreporting that is related to the persistent perception that assaults are
part of the job.
Many nurses do not report violent incidents for a variety of reasons: such as,
believing that reporting does not make any difference since violence is
expected and tolerated, that incidents are seen as a sign of their
incompetence, or that they might encounter retaliation by management or
administration. Key barriers to the reporting of a violent or aggressive act
include intimidation and a belief that in such acts will be tolerated. Others
fear that the other healthcare staff will view them as alarmists and
inadequate to handle the stress and relationships supporting patient care.
Many nurses do not report incidents because they feel workplace violence is
part of the job such as in ED or psychiatric units where violent patients are
not uncommon.
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Other reasons assaults may not be reported include the perception that the
reporting process is too time consuming, doubts about the benefits of
reporting, and feeling sorry for the patients or residents. Lack of a consistent
definition for violent behavior is also a contributing factor in underreporting.
The interpretation of what behaviors or actions constitute a violent act can
be subjective or situational in nature. A confused elderly patient who attacks
a nurse may not be identified as violent but instead confused. Also, concerns
that assaults may be viewed as a result of poor job performance or worker
negligence may lead to fears about job security.
Among healthcare workers, nurses and patient care assistants (PCAs)
experience the highest rates of violence. Nurses are three times more likely
to be the victims of violence than other healthcare personnel and Emergency
Department (ED) nurses experience physical assaults at the highest rate of
all nurses. A 2006 study found that 67% of nurses, 63% of PCAs and 51% of
physicians had been assaulted at least once in the previous six months by
patients. A later study in 2008 showed that 2,250 hospital workers had
injuries from assaults that were serious enough to require days away from
work or restricted days, according to the U.S. Bureau of Labor Statistics,
which represented a slight increase from 2006 and 2007.21 From 2002 to
2013, incidents of serious workplace violence were four times more common
in healthcare than in private industry on average, according to the Bureau of
Labor Statistics data.
Workplace violence is not only an issue in hospitals; it is also a significant
problem in nursing homes and long-term care facilities. One study showed
that the most assaulted worker in the U.S., is the aide working in a nursing
home. Based on self-reports, up to 70% of nursing home staff are assaulted
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at least once a month. When nursing home workers are physically assaulted
it is frequently by the residents for whom they care, or by residents’ visitors
or family members. Violence may partially explain the very high employee
turnover rate in nursing homes (25% to 150% annually).4
Several major professional nursing organizations have issued position
statements or directives outlining intolerance of workplace violence and
highlighting their support for the creation of safer work environments
including the American Nurses Association (ANA), Emergency Nurses
Association (ENA), American Psychiatric Association (APA), and the Canadian
Nurses Association (CNA). Violence has become so prevalent globally that
the International Labor Organization (ILO), International Council of Nurses
(ICN), World Health Organization (WHO), and Professional Service Industries
(PSI) have jointly issued guidelines to address workplace violence in the
health care environment. According to this joint alliance, workplace violence,
“be it physical or psychological, has become a global problem crossing
borders, work settings and occupational groups.”10 In addition, the
Occupational Safety and Health Administration (OSHA) have issued violence
prevention guidelines for health care workers. In 2003, the American
Association of Occupational Health Nurses Inc. (AAOHN) signed an alliance
with OSHA, renewed in 2005 and 2007, regarding workplace violence. The
American Association of Occupational Health Nurses Inc., agreed to promote
national dialogue on workplace safety and health and to provide outreach
and communication regarding the problem.3
The American Association of Critical Care Nurses (AACN) position statement
on workplace violence prevention includes a call to action for institutions and
nurses. The AACN demands the provision of a safe workplace, including
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written policies, employee training, proper staffing, and investigation of any
incidents. It also mandates the implementation of a comprehensive policy for
preventing and managing workplace violence that establishes a clear
expectation of employee behavior and a course of action for employees and
managers to take when workplace violence occurs with full administrative
support for these policies.
Violence In Healthcare Settings
Violence in the healthcare setting affects the employee, employer, and
patients. In addition to physical injury and disability, chronic pain, and
muscle tension, employees who experience violence suffer psychological
problems such as loss of sleep, nightmares, and flashbacks. Healthcare
workers who are assaulted experience short-term and long-term emotional
reactions, including anger, sadness, frustration, anxiety, irritability, apathy,
self-blame, and helplessness. One 2006 study found that assaulted nursing
assistants in long-term care facilities were significantly more likely to suffer
occupational strain, role stress, anger, job dissatisfaction, decreased feelings
of safety, and fear of future assaults.7 Symptoms occurred regardless of
whether an injury was sustained from the assault. These effects are
significant; as demonstrated in a 2004 study that found at-risk healthcare
workers frequently suffer symptoms of post-traumatic stress disorder
(PTSD) assaults.7 The consequences of workplace violence continue after a
violent event, affecting quality of life for years after the event. There is a
long list of physical symptoms and behaviors reported by the victims of
workplace violence, some of which include anger, sadness, frustration,
irritability, fear, self-blame, increased stress levels and stress-related illness,
sleeplessness and loss of appetite, weight loss or gain, gastrointestinal
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disorders, fatigue, headache, increased smoking, drinking, or drug use,
depression, post-traumatic stress syndrome and loss of relationships.
Male nurses report higher levels of physical and nonphysical violence than do
female nurses. Younger age and having an associate degree education
(versus a diploma or bachelor’s degree) are related to increased physical
and nonphysical workplace violence. In addition, nurses who have poor
interpersonal relationships with supervisors, management, colleagues,
physicians and/or administration are at higher risk for experiencing
workplace violence. Race and the number of years worked as a nurse or in a
particular department appear to have little effect on the experience of
violence in the workplace. Further consequences of workplace violence
include absenteeism, higher turnover and job dissatisfaction. A study
completed by the ANA in 2001 found that 54% of nurses would not
recommend nursing as a profession.14 Fewer than 20% of the respondents
felt safe at work, and almost 60% reported they were threatened or verbally
abused during the past year. Overall 90% of nurse respondents cited health
and safety concerns as influencing their decision to continue working in the
nursing profession. Research reveals that nursing is a violent profession,
second only to law enforcement in the violence that occurs at work.
Other consequences of workplace violence include changes in employee
morale, job stress, employee turnover, reduced quality of life, and a change
in the culture or overall working environment. Workplace violence and
patient aggression can cause nurses to adopt non-productive strategies for
coping with anxiety that are consequentially detrimental to the quality of
care. One good example of this in the clinical setting is nurses employing
“patient-avoiding behaviors” or “social distancing” (i.e., avoiding verbal
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interaction or talking and listening to patients less than other colleagues on
non-violent units). Negative staff attitudes and the use of such controlling or
coercive behavior in managing patient aggression and violence can be
associated with higher levels of patient aggression that may consequently
become a vicious cycle in the clinical setting.
Poor performance, lost productivity, and loss of self-confidence,
concentration, and creative problem-solving capacity could put the nurse
and patient in danger. Abusive work situations can lead health care
professionals to make mistakes, the consequences of which patients must
suffer. Patient safety is further compromised when communication flow is
interrupted, collegial relationships are weakened, and team collaboration is
disrupted. These consequences of workplace violence have been shown to
increase the potential for medical errors or adverse events.22 Other negative
effects of violence on patient safety include disruption in distribution of pain
medications resulting in unnecessary or prolonged pain for the patient,
patients receiving other medications or antibiotics late, administration of
incorrect medications, misdiagnosis, performance of wrong site surgeries
and death. An important aspect of a culture of safety is creating a violencefree work environment of mutual respect, dignity, and fairness that nurtures
teamwork and open communication.
In 2001, the Bureau of Justice Statistics released the findings of its National
Crime Victimization Survey on Violence in the Workplace. This showed that
significant costs are associated with workplace violence. These costs include
medical expenditures, lost wages, legal fees, insurance administrative costs,
lost fringe benefits, increased security measures and household production
costs. The cost per case for assaults to registered nurses has been estimated
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at $31,643 and $17,585 for licensed practical nurses and up to $13.5 billion
per year nationwide; however, this figure is difficult to determine since only
20% of private industry and 36% of government establishments track the
cost of incidents related to violence.4
Prevention Of Workplace Violence
Foremost, violence should never be accepted and tolerated as part of the
job. In addition, workplace policies and procedures are needed that focus on
the security of the environment, reporting and surveillance, and education
for all employees and managers on how to prevent and mange violence.
When violence does occur, it is critical that formal or informal debriefing be
offered to nurses and all staff members experiencing violence.
Unfortunately, this level of support is not found in all organizations. Many
nurses report that unless they are physically injured, they are often
expected to return immediately to their work after being physically assaulted
by a patient or visitor.
Staff should be encouraged to report violent encounters or behaviors in a
confidential manner resulting in swift response by management. This can be
supported through policies mandating documentation of certain types of
nonconsensual, nonprofessional physical contact. The Occupational Safety
and Health Administration reports that one of the best protections employers
can offer their workers is to establish a zero-tolerance policy toward
workplace violence.22 This policy should cover all workers, patients, clients,
visitors, contractors, and anyone else who may come in contact with
company personnel. The Occupational Safety and Health Administration also
states that by assessing their worksites, employers can identify methods for
reducing the likelihood of incidents occurring.
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The Occupational Safety and Health Administration believes that a well
written and implemented Workplace Violence Prevention Program, combined
with engineering controls, administrative controls and training can reduce
the incidence of workplace violence in both the private sector and Federal
workplaces. This can be a separate workplace violence prevention program
or can be incorporated into an injury and illness prevention program,
employee handbook, or manual of standard operating procedures. It is
critical to ensure that all workers know the policy and understand that all
claims of workplace violence will be investigated and remedied promptly. In
addition, OSHA encourages employers to develop additional methods as
necessary to protect employees in high-risk industries. Notably, the ANA
(2015) issued a zero-tolerance position statement entitled "Incivility,
Bullying, and Workplace Violence" emphasizing the shared ethical, legal, and
moral obligation of RNs and employers to establish and maintain safe and
healthy workplaces. The position statement provides nurses with information
on the detrimental effects of workplace violence, including physical,
psychological, and financial consequences.13
Studies conducted by OSHA show that employers who implement effective
safety measures can reduce the incidence of workplace violence. These
measures include training employees on workplace violence, encouraging
employees to report assaults or threats, and conducting workplace violence
hazard analysis. Other methods such as using entrance door detectors or
buzzer systems for entry, and providing adequately trained staff, alarms and
employee “safe rooms” for use during emergencies in healthcare settings
can help minimize risk. Many violent situations directed towards nurses
could have been avoided by recognizing early signs of aggression. Findings
from a study in a rural ED emphasized the importance of active listening,
building rapport, presenting to the patient with a calm demeanor, and being
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supportive to de-escalate aggression. Despite professional knowledge
regarding triggers for aggression, most nurses only address violent
behaviors when the behavior has escalated. Table 2 describes common
triggers and suggested actions by the nurse to de-escalate the situation.
Behaviors leading to aggression may be identified at any stage in the care
process but should initially be assessed through the admission history.
Table 2 – Common Triggers of Aggression and Violent Behaviors and Suggested
De-escalation Techniques
Common Triggers of
Aggression & Violent
Behaviors
Poor communication and
De-Escalation Techniques for Nurses
Set behavioral standards and hold staff accountable for
insensitive attitude by the
customer service skills. Consider implementation of
nurse or other care provider
emphasis on caring in the practice model.
Recent patient history of
Perform a thorough and comprehensive admission history
stressful life events
including social system and support network assessment.
(divorce, unemployment,
Address plans for support and interventions in
drug addiction, death of a
multidisciplinary care plan/conferences if appropriate.
loved one)
Atypical or increased
Communicate clearly. Solicit support for patient/family from
anxiety on the part of the
pastoral care, social services, medical staff and patient’s
patient or family.
personal support system. Provide enough time to
communicate appropriately.
Lack of availability of
Work with colleagues to increase patient trust through
clinical information in
consistency in communication and terminology and
understandable language.
language that the patient understands.
Confusion and delirium.
Use of supportive listening, allowing the patient to express
concerns when possible.
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Certain individuals are more prone to violence, so thorough evaluation for
specific diagnoses and behaviors is necessary. Violent behaviors may be
found in individuals with psychiatric diagnoses such as affective disorders
(bipolar or manic), paranoid delusions or psychosis, chemical abuse or
dependency, dementia from any cause, impulse control disorders, and
personality disorders. Additional factors that may indicate an increased risk
of violence are a history of violence against people, pets, or property, courtordered treatment for violence, and failure to take psychiatric medications.
Beyond these red flags are general characteristics that can predict violence,
including age younger than 40, single, residence in an urban area, substance
misuses, homelessness, little or no social contact, and paranoia.
Certain behaviors can signal escalation toward violence including rapid, loud
or profane speech, increased confusion or disorientation, clenched fists,
gritted teeth, reddened face, widened eyes, flaring nostrils, rapid breathing,
agitation evidenced by pacing, fear, or inability to remain still, hallucinations,
and sudden change in or extremes of affect. These behaviors are all clear
warning signs those individuals should be approached carefully and quickly.
Other warning signs that people may be near the breaking point include
veiled threats, vindictiveness, a resentful attitude, anger issues, depression,
co-worker complaints, obsessive-compulsive controlling behavior, and an
inability to get along with others.
Research by the ENA revealed that nearly 56% of patients who physically
assaulted nurses were under the influence of alcohol, 47% were under the
influence of illicit or prescription drugs and 45% were mentally ill.20 Nearly
all perpetrators in this study were patients. The ENA research also showed
there are lower rates of abuse when panic buttons, locked entries, enclosed
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nurses’ stations, call code pseudonyms, security signs and well lit areas are
used in the Emergency Department (ED); however, the most effective
approach is a violence mitigation program that includes facilities
management that listens to staff to understand what they need to keep
themselves and their patients’ safe.
Safety risks such as poorly lit hallways, parking areas, walkways and a poor
design for traffic and workflow may be inherent in the environment and can
contribute to workplace violence. Unrestricted access to entrances,
inadequate security, overcrowded waiting rooms, access to weapons, drugs
or alcohol, and the presence of addicted or psychiatric patients or visitors
with a history of violence all enhance the risk of violence. Working in an
understaffed unit or working alone also increases risk. Other organizational
risk factors include managers with poor skills, inadequate policies or failure
to enforce existing policies, lack of managerial or staff member conflict
resolution skills, lack of a reporting system, and lack of consequences for
offenders.
Organizational risk factors include uncertainty regarding patient treatment,
poor quality teamwork, time pressures, role conflict and ambiguity, high
levels of physical strain at work, frequent interruptions, irregular hours,
staffing shortages, dissatisfaction of work schedules, managers with poor
skills, inadequate policies or failure to enforce existing policies, lack of
managerial or staff member conflict resolution skills, lack of a reporting
system, and lack of consequences for offenders.
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One expert states that a respectful workplace is the best defense against
violence on the job:
“Create a culture in which violence is less likely to occur by treating
adults in a respectful manner and building respect into the company’s
policies and training. It’s also important to train staffers for
interpersonal skills and conflict resolution so that they can solve
problems in an appropriate way.”3
The Occupational Safety and Health Administration provide a workbook
entitled “Guidelines for Preventing Workplace Violence for Health Care &
Social Service Workers” (2012) and the Joint Programme on Workplace
Violence in the Health Sector has issued “Framework Guidelines for
Addressing Workplace Violence in the Health Sector (2012). Highlights of
these documents include:
1. Evaluate the Workplace
Each workplace is unique and should be analyzed for its vulnerability
to violence. A plan can then be developed that will prevent and control
these hazards. Safety and health training can occur and policies can be
disseminated. This analysis should be an ongoing process, evaluating
the effectiveness of the program so changes can be made.
2. Use a Top-Down Approach
Workplace violence must be addressed starting at the top and working
down. It is the employer’s duty to provide a safe working environment.
No prevention program has a chance of success without the support of
management.
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3. Institute Zero Tolerance
At the heart of OSHA’s guidelines for preventing workplace violence in
health care is zero tolerance, considered the minimum requirement for
a workplace violence prevention program. According to OSHA, zero
tolerance for workplace violence and verbal and nonverbal threats and
related action policies should be created and disseminated among all
managers, supervisors, workers, patients and visitors.
4. Empower Nurses
Nursing is a complex environment. More patients with higher acuity
and more complex needs can result in nurses feeling overwhelmed.
Nurses must be empowered to report incidents when they occur.
5. Predict High-Risk Events
Violence has been described as a process with three behavioral
phases; baseline, a calm phase of normal demeanor prior to
disturbance; preassault, when an individual becomes disturbed and
displays verbal and nonverbal behaviors that indicate the threat of
violence; and assault, or the acute excitement phase, when the
individual displays out of control verbal and physical behavior. The
goal is to recognize when an incident has reached the preassault phase
and intercede, leaving the spiral of violence.
6. Provide Education
A successful educational program geared toward preventing workplace
violence must be fluid and change with the needs of the organization
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in an effort to identify and reduce the risks involved. Education should
be provided to all employees, but initially to supervisors, whose
support is crucial to the success of the program. Annual retraining is
imperative, and workplace violence prevention training should begin in
nursing schools.
In a Sentinel Event Alert, the Joint Commission accrediting body reminds
hospitals of the requirement to maintain a written security plan, conduct risk
assessments, develop prevention strategies, and maintain a response plan
that would be implemented if there is a violent incident. The Joint
Commission offered the following recommendations for reducing the risk of
violence in healthcare organizations:
1. Work with the security department to audit a facility’s risk of violence.
2. Make improvements to the facility’s violence prevention program.
3. Take extra security precautions in the ED, especially if the facility is in an
area with a high crime rate or gang activity.
4. Work with Human Resources (HR) to make sure it thoroughly prescreens
job applicants and establishes/follows procedures for conducting
background checks of prospective employees and staff.
5. Confirm that HR has procedures in place for disciplining and firing
employees as a way of avoiding violent reactions.
6. Require key staff to undergo training in responding to patients’ family
members who are agitated and potentially violent.
7. Encourage employees to report incidents of violent activity.
8. Educate supervisors that all reports of suspicious behavior or threats by
another employee must be treated seriously.
9. Ensure that counseling programs for employees who become victims of
workplace crime or violence are in place.
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Management Of Workplace Violence
Even the most skilled nurses cannot prevent all instances of violence. An
initial reaction to impending aggression may be a physical restraint or a
reaction supporting physical restraint. The use of restraints should be
minimized to promote patient safety. This is especially true with staff
members that are not trained appropriately to implement and monitor
restraints and restraint use. Inappropriately applied restraints can result in
death, physical injury, emotional stress and extra work for the staff to
monitor accordingly.
Some of OSHA’s key recommendations for healthcare administrative and
work practice controls include the following:22

State clearly to patients, clients and employees that violence is not
permitted or tolerated.

Ensure that adequate and properly trained staff is available to restrain
patients or clients, if necessary.

Provide sensitive and timely information to people waiting in line or in
waiting rooms. Adopt measures to decrease waiting time.

Ensure that adequate and qualified staff is available at all times. The
times of greatest risk occur during patient transfers, emergency
responses, and at meal times and at night. Areas with the greatest risk
include admission units and crisis or acute care units.

Institute a sign-in procedure with passes for visitors, especially in a
newborn nursery or pediatric department. Enforce visitor hours and
procedures.

Establish a list of “restricted visitors’ for patients with a history of
violence or gang activity. Make copies available at security
checkpoints, nurses’ stations and visitor sign-in areas.
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
Review and revise visitor check systems, when necessary. Limit
information given to outsiders about hospitalized victims of violence.

Supervise the movement of psychiatric clients and patients throughout
the facility.

Control access to facilities other than waiting rooms, particularly drug
storage or pharmacy areas.

Determine the behavioral history of new and transferred patients to
learn about any past violent or assaultive behaviors.

Establish a system – such as chart tags, log books or verbal census
reports – to identify patients and clients with assaultive behavior
problems. Keep in mind patient confidentiality and worker safety
issues. Update as needed. Review any workplace violence incidents
from the previous shift during change in-shift meetings.

Treat and interview aggressive or agitated clients in relatively open
areas that sill maintain privacy and confidentiality (such as rooms with
removable partitions).

Use case management conferences with coworkers and supervisors to
discuss ways to effectively treat potentially violent patients.

Prepare contingency plans to treat clients who are “acting out” or
making verbal or physical attacks or threats. Consider using certified
employee assistance professionals or in-house social service or
occupational health service staff to help diffuse patient or client anger.

Transfer assaultive clients to acute care units, criminal units or other
more restrictive settings.

Ensure that nurses, physicians and other clinicians are not alone when
performing intimate physical examinations of patients.

Discourage employees from wearing necklaces or chains to help
prevent possible strangulation in confrontational situations. Urge
community workers to carry only required identification and money.
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
Survey the facility periodically to remove tools or possessions left by
visitors or maintenance staff that could be used inappropriately by
patients.

Provide staff with identification badges, preferably without last names,
to readily verify employment.

Discourage employees from carrying keys, pens or other items that
could be used as weapons.

Provide staff members with security escorts to parking areas in
evening or late hours. Ensure that parking areas are highly visible,
well lit and safely accessible to the building.

Use the “buddy system” especially when personal safety may be
threatened. Encourage home healthcare providers, social service
workers and others to avoid threatening situations.

Advise staff to exercise extra care in elevators, stairwells and
unfamiliar residences, leave the premises immediately if there is a
hazardous situation; or request police escort, if needed.
Nurses should not accept violence as a part of the job. If nurses are to
continue practicing, a plan must be formulated that sends a clear and
powerful message that workplace violence will not be tolerated. Nurses must
be taught to recognize incivility and exit the spiral before situations result in
violence.
If a violent incident cannot be predicted or prevented, the employer has a
duty to provide immediate and appropriate treatment to the victimized
employees. Immediate comfort and peer support, such as a community
meeting, expression of understanding by management, specific debriefing,
and a referral to the Employee Assistance Program should be initiated.
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Debriefing or review of procedures should occur routinely within 24-72 hours
of the event, and this process should be safe, with no attempt to place
blame. Information regarding typical adaptive and maladaptive response
patterns following a traumatic event, along with a list of resources, should
also be given to the traumatized employees.
Horizontal Violence
Constructive relationships among nursing colleagues are critical for quality
patient care and nurse retention; however, another important type of
workplace violence is horizontal or lateral violence. This is defined as overt
and covert nonphysical hostility, such as criticism, sabotaging, undermining,
infighting, scapegoat, and bickering. Horizontal violence refers to the harsh
reality experienced by some nurses beginning their careers in nursing.
Nursing researchers describe it as eating our young. Horizontal violence
includes forms of nonphysical intergroup conflicts that are manifested in
overt and covert behaviors of hostility.
Acts of horizontal violence can range from intimidating body language to
sarcastic comments and abusive language. Horizontal violence includes all
acts of unkindness, discourtesy, divisiveness, and lack of cohesiveness.
Examples include belittling gestures, verbal abuse, gossiping, sarcastic
comments, faultfinding, devaluing comments, disinterest and
discouragement, and controlling behaviors. Horizontal violence is
psychologically, emotionally, and spiritually damaging behavior and can have
devastating long-term effects on its recipients. Horizontal violence includes a
wide range and variable degrees of antagonism including innuendo,
intimidation, passive aggression, withholding information, insubordination
and verbal and physical aggression. This is not a new phenomenon, as the
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effects of horizontal violence have been reported in the literature for almost
30 years.
Covert behaviors include failure to cooperate, failing to respect privacy,
making untoward facial expressions, discouraging new staff, undermining
staff abilities, providing minimal guidance during orientation and gossiping.
The easiest targets for these behaviors are novice nurses. Novice nurses are
more susceptible to horizontal violence than seasoned nurses due to their
lack of experience. New-to-practice nurses rely on the more experienced
nurses to assist them in their professional growth. Ineffective relationships
between nurses contribute to instances of horizontal violence, making it
imperative that nurses recognize and deal with the issue.
One author describes horizontal violence as having three categories of
behaviors including harassment, discrimination and bullying.15 Harassment is
any form of unwanted behavior that may range from unpleasant remarks to
physical violence. Sexual harassment is linked to gender or sexual
orientation. Racial harassment is typified by behaviors that are linked to a
person’s skin color, cultural background, race or ethnicity. Harassment tends
to have a strong physical component in manifested behaviors. Behaviors
that include regular following and watching are termed stalking.
Discrimination involves a person being treated differently, and in particular,
less favorably because of gender, race, sexual orientation or ability.
Workplace bullying is characterized by many incidents of unjustifiable actions
of an individual or group toward a person or group over a long period.
Bullying behaviors are persistent, offensive, abusive, threatening, and
malicious in nature with the intent to do harm. The person who bullies may
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be in a position of power (actual or perceived). Bullying involves intentionally
targeting a colleague or employee and systematically creating a negative
work environment for them through degradation, social exclusion and other
negative acts aims at tormenting or frustrating the victim.
One 2001 study outlines three forms of workplace bullying: (1) work-related
bullying, such as, withholding information or imposing unreasonable
deadlines; (2) personal bullying, such as, gossiping or spreading rumors;
and, (3) physical bullying, such as being shouted at or threatened with
physical abuse.15 This study describes that, to be considered bullying the
behavior must occur a minimum of once a week over a period of
approximately six months, and the instigating party must have power over
the intended target. Another study, conducted in 2009, found a bullying
prevalence of 27% which is significant as nurses labeled as bullied were
twice as likely to want to leave their current position, and three times more
likely to want to leave the nursing profession.9
Work-life factors common in nursing environments such as role conflict, role
ambiguity, role overload, work constraints and autonomy, have all been
found to be antecedents of horizontal violence. In one 1997 study, that
attempted to clarify what nurses report as aggression in their workplace and
the extent and importance attached to aggression from colleagues, all 29
respondents reported that inter-staff aggression was more upsetting and
problematic to deal with than aggression from patients or other disciplines.
One of the researcher’s conclusions was that “it is paradoxical that within a
discipline that has ‘caring’ for others as its main focus employee
relationships are so poor.”11
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As with other types of workplace violence, the actual incidence is difficult to
determine. One 1999 study revealed that, of the 270 nurses surveyed, 30%
indicated that they dealt with aggression daily whereas 25% indicated that
colleague aggression was a major stressor in the work environment (KingJones, 2011). Another study in 2003 concluded that sabotage or
undermining and destroying of integrity is prevalent. Of the 145
respondents, 87% reported they were expected to do the work of others and
73% reported they were not acknowledged for the work they completed.
This researcher also reported that 79% of respondents reported being
reprimanded in front of others.15
This is such a significant issue, for novice and seasoned nurses alike, that
organizations such as The Joint Commission and the AACN are taking an
active role in addressing the issue of horizontal violence by advocating for
healthy work environments. The Joint Commission issued Sentinel Event
Alerts in 2009, 2010 and 2011 that address violence and incivility in health
care and recommend that the health care organizations take steps to end
intimidating and disruptive behavior.
The Joint Commission mandates that organizations develop and implement
processes to offset horizontal violence that enforce a code of conduct, teach
employees effective communication skills, and support staff members
affected by bullying. The AACN identified six essential standards, one of
which is skilled communication, to offset behavior that leads to horizontal
violence.9 The AACN further advocates that nurses’ communication skills
should be as proficient as their clinical skills.
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Consequences of Horizontal Violence
The consequences of this unprofessional behavior yield lessened job
performance, satisfaction, and morale; and greater turnover and
absenteeism. Ultimately, the effects of the continual stress from horizontal
violence may culminate in health problems such as hypertension, diabetes,
coronary artery disease, depression, panic disorders, and post-traumatic
stress disorder. Other effects of horizontal violence include:

Clinical errors

Decreased productivity

Marginalization of the competencies, intelligence and integrity of others

Reduced self esteem

Disconnection

Apathy and low morale

Depression, anxiety and sleep disorders

Difficulty with motivation

Difficulty with emotional control (bursting into tears)

Impaired personal relationships (trust is destroyed, eroding relationships
in the workplace and creating a major obstacle to team building)

Post-traumatic stress disorder

Negative somatic symptoms

Emotional exhaustion

Fatigue and sickness

Decreased mental health and emotional well being
Traumatic symptomatology includes:

Loss of ability to manage everyday situations

Over-reactive response, such as dissociation and psychic numbing

Memory dysfunctions
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
Activation of the brain’s circuit breakers
There are many forms of dissociative responses including forgetfulness,
spacing, speechlessness, depersonalization and derealization, and fugue or
amnesic state due to severe stress. This puts the nurse at great risk of
omissions and errors in patient care. Horizontal violence in the workplace
creates an unsafe and unhealthy environment where everyone is negatively
affected. Co-workers may feel very sorry for the nurse being targeted but
are fearful of taking action as they worry that they will become the next
target. Some may even side with the bully and blame the victim. Covert
behaviors of horizontal violence are just as detrimental as overt behaviors.
Many nurses may unwittingly not be aware they are exhibiting horizontal
violence. Regardless, these behaviors are destructive. It is imperative that
nurses become aware of their behaviors and make a conscious decision not
to perpetrate horizontal violence toward staff. Becoming a skilled
communicator is essential to developing good interpersonal relationships. It
is helpful that organizations are taking a stand to eradicate horizontal
violence, but nurses must take responsibility and accountability for caring for
self and others by confronting staff members who are causing the problem.
By not speaking up, nurses risk the chance of devaluing themselves. Skilled
communication is the common thread that weaves relationships together,
lending itself to the prevention of horizontal violence.
Strategies to Combat Horizontal Violence
In some workplaces, an interdisciplinary team consisting of leadership from
management, administration, as well as the occupational and safety nurse
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and other experts initiate the process of creating a culture of civil behavior.
The aim is to rebuild social relationships focus on prevention and repair the
harm from horizontal violence. This process is also sensitive to
acknowledging that changing culture takes time, requiring wisdom,
compassion, diligence and patience. Naming the actions and behaviors that
are unacceptable is a step toward controlling inappropriate behavior and
moving toward a culture of patient safety. Three creative strategies to do so
described in the literature include code pink, code purple and CUSS words.11
Code Pink
A code pink situation occurs when everyone in earshot of a disruptive
behavior comes together and surrounds both participants, standing silently
with arms crossed to provide support for the victim. The perpetrator usually
realized his or her poor behavior and the silent disapproval of it, and the
poor behavior often ceases. If it does not, management personnel may have
to become involved.
Code PURPLE
The acronym PURPLE stands for Please Use Respectful Professional Language
Every time. Nursing staff members can educate others by hanging posters
about the concept around the unit and then verbally calling out a “code
PURPLE” when someone acts inappropriately.
CUSS Words
The third strategy is for staff members to use the words “concerned,”
“uncomfortable,” “scared,” or “stop” (i.e., CUSS words) proceeded by an “I
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am” or “I want” statement; i.e., “I am uncomfortable with your behavior.” “I
want you to stop yelling at me.” When one of these CUSS words is used, it
should signal the team to stop and take an account off what is happening. It
is a way to empower every level of practitioner to safely call attention to an
environment that could potentially cause a serious error.
Summary
Workplace violence is a significant issue that crosses all nursing work
environments and has far reaching consequences. Patient, family and visitor
aggression and violence towards nurses is a common phenomenon seen for
nurses working in a variety of care environments. The aftermath effects are
found to be associated with negative psychological and emotional responses
and job dissatisfaction that can reciprocally lead to inadequate quality of
care and a vicious cycle of patients’ aggression and violence towards nurses.
This is a significant issue as the Bureau of Labor Statistics found that nurses
were victims of nonfatal assaults more than twice as often as any other
medical field workers.
Workplace violence can take many forms and be either overt and obvious, or
covert and hidden. Any type of workplace violence can have serious
consequences for all involved and should not be tolerated by the staff or
management or administration of the organization. This course has
described the different types of workplace violence, discussed the incidence
of workplace violence, its consequences, and some strategies to prevent and
deal with occurrences of workplace violence as well as some online resources
that may be helpful in the further study of workplace violence.
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Online resources helpful for information on workplace violence:

http://www.osha.gov/Publications/osha3148.pdf

http://www.cdc.gov/niosh/docs/2012-118/pdfs/2012-118.pdf

http://www.osha.gov/SLTC/workplaceviolence/index.html

http://www.cdc.gov/niosh/docs/video/violence.html

http://www.health.nsw.gov.au/pubs/2007/nwr_report.html

http://www.who.int/violence_injury_prevention/violence/activities/wor
kplace/en/

http://www.who.int/violence_injury_prevention/violence/en/

http://www.osha.gov/Publications/OSHA3148/osha3148.html

www.ena.org/IENR/ViolenceToolKit/Documents/toolkitpg1.htm

http://www.icn.ch/pillarsprograms/workplace-violence-in-the-healthsector/workplace-violence-in-the-health-sector-858.html
Please take time to help NurseCe4Less.com course planners evaluate
the nursing knowledge needs met by completing the self-assessment
of Knowledge Questions after reading the article, and providing
feedback in the online course evaluation.
Completing the study questions is optional and is NOT a course
requirement.
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1.
______ % of all nonfatal injuries from occupational assaults and
violent acts occur in healthcare and social service settings.
a. 25 %
b. 48 %
c. 15 %
d. 33 %
2.
True of False. Workplace Type I incidents involve offenders in a
relationship with either the victim or the establishments.
a. True
b. False
3.
Healthcare workers are at increased risk for workplace violence
due to multiple factors, including:
a. prevalence of handguns/weapons among patients and the public
b. use of hospitals for holds on acutely disturbed, violent individuals
c. availability of drugs or money at health sites and pharmacies.
d. all of the above
4.
True of False. A Workplace Violence Prevention Program with
training can reduce the incidence of workplace violence.
a. True
b. False
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5.
An important aspect of a culture of safety is creating a:
a. violence-free work environment
b. work environment of mutual respect and dignity
c. fairness that nurtures teamwork and open communication
d. all of the above
6.
The following can contribute to the potential for violence in the
workplace:
a. Working alone or in isolated areas.
b. Time of day.
c. Location of work.
d. All of the above.
7.
True or False. Male nurses report higher levels of physical and
nonphysical violence than do female nurses.
a. True
b. False
8.
Organizational risk factors leading to workplace violence include
all of the following EXCEPT:
a. staffing shortages
b. poor quality teamwork
c. a reporting system, leading to staff fear of being reported.
d. All of the above.
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9.
True or False. Workplace bullying is characterized by many
incidents of unjustifiable actions of a group (but not an
individual) toward a single person (not involving a group) over a
long period.
a. True.
b. False.
10. Bullying behaviors are all EXCEPT
a. harmful, although often not meaning to be.
b. persistent.
c. offensive.
d. threatening.
11. Bullying involves
a. unintentionally targeting a colleague or employee
b. systematically creating a negative work environment for a colleague
or employee through degradation
c. social inclusion
d. Both a and b above.
12. At the heart of OSHA’s guidelines for preventing workplace
violence in health care is
a. zero tolerance
b. horizontal violence
c. maximum prevention
d. lateral violence.
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13. Organizations such as The Joint Commission and the AACN are
taking an active role in addressing the issue of
____________________ by advocating for healthy work
environments.
a. sexual harassment
b. lateral violence
c. horizontal violence
d. Both a and b above.
14. True or False. Passive Aggressive behavior includes eye rolling,
raising eyebrows, making a face, turning away from a person, or
physically excluding someone.
a. True.
b. False.
15. Nurses labeled as bullied were twice as likely to want to leave
their current position, and three times more likely to want to
leave the nursing profession
a. three times; twice
b. five times; ten times
c. twice; three times
d. three times; five times
16. Highlights of the Framework Guidelines for Addressing
Workplace Violence in the Health Sector (2012) included all
EXCEPT:
a. Evaluate the workplace
b. Evaluate nurses
c. Empower nurses
d. Provide education
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17. When evaluating the workplace vulnerability for violence, a plan
should
a. include ongoing analysis
b. include periodic analysis
c. focus on horizontal violence as the main problem of workplace
harassment
d. include retreats for management to learn about lateral violence.
18. According to ________________________________, a zero
tolerance approach to prevent workplace violence in health care
should be created and disseminated among all managers,
supervisors, workers, patients and visitors.
a. OSHA
b. ANA
c. Joint Accreditation
d. most state laws governing hospitals
19. Three behavioral phases of violence are
a. passive, aggressive, hostile.
b. preassault, violence, intercede.
c. baseline, preassault, and assault.
d. None of the above.
20. Education on workplace violence should be initially provided to
a. employees
b. supervisors
c. administration
d. workplace bullies
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21. True or False. Retraining on workplace violence should be every
2 years (not an annual requirement) because of the cost and
extensive use of resources for employers to organize such an
effort.
a. True.
b. False.
22. Common triggers of aggression and violent behaviors include
a. poor communication.
b. increased anxiety
c. confusion and delirium
d. All of the above.
23. A general characteristic for predicting violence includes
a. age older than 40.
b. age younger than 40.
c. being elderly.
d. residence in rural setting.
24. CUSS Words, the third strategy staff members to address an
issue of violence would include statements such as
a. “I want you to stop yelling at me.”
b. “Would you please consider not raising your voice?”
c. “I’m going to yell at you if you don’t stop.”
d. “You’re hurting my feelings.”
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25. True or False. Key barriers to the reporting of a violent or
aggressive act include intimidation and a belief that in such acts
will be tolerated.
a. True.
b. False.
26. A study in 2003 on workplace violence found the following were
prevalent features:
a. sexual harassment
b. sabotage and destroying of integrity
c. racial discrimination
d. Both a and c above.
27. A majority of nurses in certain studies reported they were
a. expected to do the work of others.
b. not acknowledged for the work they completed.
c. had been reprimanded in front of others.
d. All of the above.
28. Novice nurses have been identified as easy targets of
a. lateral violence.
b. racial discrimination.
c. horizontal violence.
d. None of the above.
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29. Horizontal violence has been identified as having three
categories of behaviors including
a. harassment, discrimination and bullying.
b. inequitable pay, job opportunity and benefits.
c. physical, mental and emotional abuse.
d. isolation, embarrassment and fear.
30. True or False. Harassment tends to have a strong physical
component in manifested behaviors.
a. True.
b. False.
31. Assaulted nursing assistants in long-term care facilities were
significantly more likely to suffer
a. occupational strain.
b. role stress.
c. job dissatisfaction.
d. All of the above.
32. True or False. Race and the number of years worked as a nurse
or in a particular department appear to a major effect on the
experience of violence in the workplace.
a. True.
b. False.
33. Research reveals that nursing is a violent profession, second
only to ___________________.
a. law enforcement.
b. sports.
c. security guards.
d. cab drivers
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34. Workplace violence has been divided into four categories. Type
IV incidents involve
a. offenders who have no relationship with the victim.
b. offenders currently receiving services from the facilities when they
commit an act of violence.
c. incidents, domestic disputes between an employee and the
perpetrator.
d. current or former employees acting out toward their present or
former places of employment.
35. Debriefing or review of procedures should occur routinely within
___________ hours of the event, and this process should be
safe, with no attempt to place blame.
a. 24 – 72
b. 12 – 24
c. 36 – 48
d. less than 24 hours.
Correct Answers:
1. b
6. d
2. b
7. a
3. d
8. c
4. a
9. b
5. d
10. a
11. b
16. b
21. b
26. b
12. a
17. a
22. d
27. d
13. c
18. a
23. b
28. c
14. b
19. c
24. a
29. a
15. c
20. b
25. a
30. a
31. d
32. b
33. a
34. c
35. a
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References Section
The reference section of in-text citations include published works intended as
helpful material for further reading. Unpublished works and personal
communications are not included in this section, although may appear within
the study text.
1.
Boon-Chuan, E. (2010). A systematic literature review: Managing the
aftermath effects of patient’s aggression and violence towards nurses.
Singapore Nursing Journal, 37 (4), 18-24.
2.
Esmaeilpour, M., Salsali, M., Ahmadi, F. (2010). Workplace violence
against Iranian nurses working in emergency departments.
International Nursing Review, 130-137.
3.
Gallant-Roman, M.A. (2008). Strategies and Tools to Reduce Workplace
Violence. AAOHN Journal, 56 (11), 449-454.
4.
Gates, D.M., Gillespie, G.L. & Succup, P. (2011). Violence Against
Nurses and its Impact on Stress and Productivity. Nursing Economics,
29 (2), 59-66.
5.
Campbell, J.C.; Messing, J.T.; Kub, J.; Agnew, J.; Fitzgerald, S.; Fowler,
B.; Sheridan, D.; Lindauer, C.; Danesh, V.C., Malvey, D. & Fottler, M.D.
(2008). Hidden Workplace Violence, What your nurses may not be
telling you. The Health Care Manager, 27 (4), 357-363.
6.
Deaton, J. & Bolyard, R. (2011). Workplace Violence; Prevalence and
Risk Factors in the Safe at Work Study. JOEM, 53 (1), 82-89.
7.
Fairley, J. (2010). Strategies that avoid workplace violence, a rising
threat. Business Insurance, 44 (40), 31.
8.
Griffin, C. (2011). Empowerment Strategies for Medical-Surgical Nurses
Dealing with Lateral Violence. MedSurg Matters! 20 (5), 4-5.
9.
Hardin, D. (2012). Strategies for Nurse Leaders to Address Aggressive
and Violent Events. JONA, 42 (1), 5-8.
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10. King-Jones, M. (2011). Horizontal Violence and the Socialization of New
Nurses. Creative Nursing, 17 (2), 80-86.
11. McNamara, S.A. (2010). Workplace Violence and Its Effects on Patient
Safety. AORN Journal, 92 (6), 677-682.
12. Martin, E. (2015). WORKPLACE VIOLENCE: INCREASED FOCUS ON
SAFETY IN HEALTH CARE SETTINGS. Texas Nursing, 89(4), 13-14 2p
13. Miranda, H., Punnett, L., Gore, R. & Boyer, J. (2011). Violence at the
workplace increases the risk of musculoskeletal pain among nursing
home workers. Occupational Environmental Med, 68, 52-57.
14. OSHA issues tools to help prevent workplace violence. (2016). American
Nurse, 48(1).
15. Pontus, C. & Scherrer, D. (2011). Is it lateral violence, bullying or
workplace harassment? Massachusetts Nurse, April, 16-17.
16. Pontus, C. (2010). Warning: Nurses experience violence in this
emergency department. Massachusetts Nurse, Oct, 11.
17. Roche, M., Diers, D., Dulfield, C. & Catling-Paull, C. (2010). Violence
Toward Nurses, the Work Environment, and Patient Outcomes. Journal
of Nursing Scholarship, 42 (1), 13-22.
18. Romano, S.J., Levi-Minzi, M.E., Rugala, E.A. & Van Hasselt, V.B. (2011).
Workplace violence Prevention: Readiness and Response. FBI Law
Enforcement Bulletin, Jan., 1-10.
19. Spence Laschinger, H.K. & Grau, A. L. (2012). The influence of personal
dispositional factors and organizational resources on workplace
violence, burnout, and health outcomes in new graduate nurses: A
cross sectional study. International Journal of Nursing Studies: 49, 282291.
20. Taylor, J. L. & Rew, L. (2010). A systematic review of the literature:
workplace violence in the emergency department. Journal of Clinical
Nursing, 20, 1072-1085.
21. Whelan, T. (2008). The Escalating Trend of Violence Toward Nurses.
Journal of Emergency Nursing, 34, 130-133.
22.
Workplace Violence (2012). Retrieved July 1, 2012, from
http://www.osha.gov/SLTC/workplaceviolence/index.html
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23. World Health Organization (2002). Workplace Violence. International
Labour Organization, International Council of Nurses, World Health
Organization and Public Services International. Geneva, Switzerland.
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