Intent

The intent of this position statement is to:

• Acknowledge the critical need for increased awareness of the impact of violence in the healthcare workplace;
• Promote the education of registered nurses to assess, prevent and manage violent incidents in their workplace as well as advocate for needed resources; and
• Support registered nurse collaboration with healthcare leadership to reduce the impact of violence in the workplace.

POSITION

The position of the New York State Nurses Association is:

Registered professional nurse responsibility

• Advocate for a culture of safety and support for a comprehensive violence prevention program in all areas of practice (American Nurses Association (ANA), 2006).
• Collaborate in the creation of violence prevention programs and policies that are grounded in the Code of Ethics for Nurses with Interpretative Statements to ensure safe quality care for patients (ANA, 2006).
• Participate in interactive education programs about workplace violence prevention to empower registered nurses to respond appropriately to real or perceived violent situations (Gallant-Roman, 2008).
• Intervene when they witness aggression among their colleagues, recognize factors that may predispose patients to becoming violent, and report all incidents of violence (American Psychiatric Nurses Association, 2008).

Employers/healthcare organization responsibility

• Implement policies that support violence-free workplaces through comprehensive workplace violence prevention programs and freedom from retaliation for reporting (ANA, 2006).
• Collaborate with all staff and functions within the organization to complete a systematic and proactive workplace risk assessment to determine the nature/cause of violence (Occupational Safety Health Administration (OSHA), 2004).
• Establish policies and security practices to prohibit weapons in healthcare facilities and schools (OSHA, 2004).
• Create and maintain a healthy work environment and culture of safety by actively involving employers, healthcare organizations and registered nurses (Joint Commission, 2007).
• Provide ongoing staff education and training in assessment, prevention and resolution of workplace violence to ensure patient and staff safety (OSHA, 2004).
• Provide training to new or reassigned employees, visiting staff, temporary staff and physicians (OSHA, 2004).
• Provide well trained security staff in areas documented as high risk, that are accessible on a non-emergency as well as emergency basis and respond to perceived, potential or actual aggressive or assaultive behaviors which risk harm to patients and/or staff (OSHA, 2004).
• Support registered nurses by making the public aware of changes to Penal Law, subdivision 3 of Section 120.05 that add registered nurses to assault of emergency medical professionals and provides for Class D felonies for serious physical injury to them, and preventing them from performing an assigned duty (NYS Penal law).

BACKGROUND

Violence is a public health emergency that pervades all socioeconomic segments of society and is recognized as a global problem. In response, workplace guidelines define workplace violence; strategies for prevention and follow up; and acknowledge the need for employers to have a responsive comprehensive approach to the reality of workplace violence. These have been developed by organizations including the International Council of Nurses (ICN), the Centers for Disease Control and Prevention (CDC), OSHA and the Joint Commission. More research is required regarding the effectiveness of violence prevention efforts and what evidence supports revision and/or improvement of existing prevention programs.

In 2001 the ANA released the Bill of Rights for Nurses to emphasize that nurses and their patients have the right to a safe work environment (The American Nurse, 2002). In 2006, the ANA adopted principles related to nursing practice and a healthy work environment. The resolution advocates for a comprehensive approach to workplace security and violence prevention program and the right to a healthy work environment free of abusive behavior and reprisal (ANA, 2006).

Underreporting

Research supports a variety of reasons for registered nurses not reporting episodes of violence including a persistent perception of violence being part of the job, episodes of non-injury or nonphysical violence, lack of support by the employer or fear of reprisal, difficult reporting mechanisms, and poor documentation or investigation by employers (Gallant-Roman, 2008a).

Disruptive behaviors

Disruptive behaviors, which can include horizontal/lateral violence, vertical violence(superior to subordinate), bullying, gossiping, undue criticism, bickering and blaming, undermining and scapegoating, all add to an unhealthy workplace, as well as contribute to staff dissatisfaction; patient complaints, and the potential for errors (Joint Commission, 2008; Longo, 2010; Weinand, 2010). Literature demonstrates that disruptive behaviors are sustained by disrespect in the workplace and affect every member of the healthcare team. Socialization of student and graduate nurses can be affected leading to disillusionment of the profession (King-Jones, 2011). King-Jones (2011) noted in a literature review of bullying towards student and graduate nurses that many reported verbal abuse and considering leaving the organization or profession, as a result. The behaviors are often justified by the perpetrator as the result of poor staffing, workload or stress (Thomas & Burk, 2009). When organizations and leadership allow these behaviors to continue through tolerance and indifference, it indirectly promotes the behavior as acceptable (Longo, 2010; Pontus & Scherrer, 2011). These behaviors have become part of the nursing culture to the point of acceptance as part of the job (Longo, 2010; Sellers, Millenbach, Kovach, & Yingling, 2009-2010). When the behaviors are demonstrated or allowed by leadership, the results can include underreporting; increased turnover; absenteeism; a hostile work environment and compromised patient care (Longo, 2010; Olender-Russo, 2009; Pontus & Scherrer, 2011).

In response to nurses who reported disruptive behaviors at their workplace, in 2008, the Joint Commission released a Sentinel Alert. Recommendations within the alert suggest healthcare facilities develop policies addressing disruptive behaviors; implement a systems approach to address disruptive or intimidating behaviors; increase employee awareness of bullying behaviors and its effect on the workplace; provide training and support for employees; and conduct assessments, interventions and document follow through (Joint Commission, 2008). In 2010 the American Nurses Association House of Delegates reaffirmed full support of the previous resolution in 2006 to work proactively towards the reduction of abuse, harassment and bullying of nurses, as well as consequences related including reprisal and retaliation. The ANA also resolved to explore collaborative relationships to ensure resources for education and research (ANA HOD, 2010).

Risk factors

Gallant-Roman notes young inexperienced nurses are more at risk as are nurses who work in the emergency room, geriatric settings and mental health settings (2008a). Several studies indicate violence often takes place during times of high activity and interaction with patients, such as meal times, during visiting hours, and patient transportation (CDC, 2002, Publication 101). Additional risk factors for violence include but are not limited to tolerance and indifference towards intimidation or disruptive behavior; individual and emotional factors; embedded healthcare environment dynamics such as fear of litigation or retaliation, increased productivity demands, and limited resources (Joint Commission, 2008).

While risk factors may differ in each setting, the approach to comprehensive assessment, intervention, and prevention workplace violence is of upmost importance (Joint Commission, 2008; OSHA, 2004). Registered Nurses are expected to actively collaborate with healthcare leadership in conducting proactive risk assessments to assess environmental, behavioral, and practice factors that contribute to the occurrence of violence.

Strategies

Establishing an effective and comprehensive violence prevention program requires employer support at all levels. Ongoing education includes assessment techniques and identification of the types of violence that may be encountered by the employee; methods to avoid or diffuse potentially violent situations; mechanisms for reporting and documenting episodes of violence; and recognition of risk factors and continuing assessment of the environment by interdisciplinary teams (OSHA, 2004). In the event of an incident the process should include but not be limited to immediate medical attention as indicated; reporting and dissemination of information to the appropriate individuals including law enforcement; debriefing and referrals for employees involved or witness to an incident; and thorough documentation and evaluation of the situation to identify contributing factors to help in prevent reoccurrence (ERCI, 2005, p. 13)

Consequences

The consequences of violence are serious for both an employer and employee. Victims of workplace violence are at increased risk of long-term emotional problems and post-traumatic stress disorder (PTSD), a disorder which is common in combat veterans and victims of terrorism, crime, rape and other violent incidents. Although specific physical symptoms have not been widely researched, a large number of studies have examined the relationship between psychiatric symptoms, social effects and health- service outcomes and PTSD in both the veteran and general populations (American Psychiatric Association, 2011). Literature that has generated data regarding the associations between physical illness to PTSD including cardiovascular, gastrointestinal and musculoskeletal disorders in victims of violence, have been self-reported, indicating the need for larger epidemiological trials in the general population (Qureshi, Pyne, Magruder, Schulz, & Kunik, 2009). For more specific information regarding the clinical diagnosis of PTSD and other resources go to http://www.healthyminds.org/Main-Topic/Posttraumtic-Stress-Disorder.aspx.

Organizations are significantly affected by low worker morale, increased job stress and turnover, reduced trust of management and coworkers, and hostile work environments (CDC, 2002). “Working in fear for your personal safety can function as a major occupational stressor, and indeed, violence in the workplace has been cited as a common reason for resignation in nursing” (Opie, et al., 2010, p. 22). 
Research indicates that nurses may predispose themselves to violence, because of learned behavioral patterns, lack of autonomy and control over the practice environment (Gallant-Roman, 2008a). Further research is required regarding the impact of workplace violence on retention and recruitment of nurses in all healthcare settings.

Taking steps to improve healthcare environments will improve patient outcomes, improve retention and recruitment of registered nurses, reduce costs and improve patient and staff satisfaction, and reduce costs. Registered nurses and the public can advocate for safe and quality healthcare, but without creating safe and healthy work environments for employees, the perpetuation of these issues will continue to erode healthcare delivery systems.

RECOMMENDATIONS

The New York State Nurses Association recommends that:

• Employers/ healthcare organizations establish a health and safety committee that includes registered nurses to evaluate, monitor, address, and evaluate violence through a comprehensive workplace violence prevention program (OSHA, 2004).
• Employers/healthcare organizations create and disseminate a workplace violence policy that maintains medical and executive leadership accountability and responsibility (OSHA, 2004).
• Employers/healthcare organizations ensure data collection, pre and post occurrence of violence; aggregation of the data; analysis of the data by leadership in collaboration with registered nurses/direct care staff; planned actions to reduce violence, and evaluation of the effectiveness of the actions are important to the success of violence programs in all settings (OSHA, 2011; U.S. Department of Health and Human Services, 2006).
• Employers/healthcare organizations communicate the expectations of workplace violence prevention programs to all individuals providing and receiving services (OSHA, 2004).
• Employers/healthcare organizations ensure no employee who reports an incident will experience reprisal (ANA, 2006).
• Employers/healthcare organizations ensure that an accessible, straightforward, user friendly incident reporting process (e.g., notifying department managers or security, activating codes) are in place and that all employees receive instruction on these procedures (ECRI, 2005).
• Employers/healthcare organizations investigate all incidents and threats, monitor trends in violent incidents by type or circumstance, and institute corrective actions (OSHA, 2004).
• Registered nurses advocate for effective assessment and intervention, medication management protocols, and use of safe physical restraint procedures within approved guidelines with demonstrated registered nurse competency in high risk settings (OSHA, 2004).
• Registered nurses advocate for specialized education focused on violence prevention, identification and crisis intervention and to have protocols in place for use during at risk events (OSHA, 2004).
• Nurse educators play a key role in the prevention and reduction of workplace violence and are strongly encouraged to incorporate research evidence and best practice initiatives into nursing curricula (Gallant-Roman, 2008).
• Access to support services is available for victims of violence. Assist victims through the legal process, and with psychologically appropriate services (CDC, 2002).
• Access to legal support services is available to patients who have been the aggressor in acts of violence against nurses or other individuals during follow-up and prosecution (OSHA, 2004).

Approved by the Board of Directors on September 27, 1983; April 8, 2005; August 25, 2011.
Reviewed and revised by the expanded Council on Nursing Practice on January 21, 2005; Council on Nursing Practice June 17, 2011.

Note: The use of the term “patient” anywhere in this document is intended to be generic and refers to the recipient of nursing care.

REFERENCES

American Association of Critical-Care Nurses. (2004). Workplace violence prevention. Retrieved from http://www.aacn.org/WD/Practice/Docs/Workplace_Violence.pdf

American Nurses Association. (2002). Know your rights: ANA’s bill of rights arms nurses with critical information, The American Nurse, 34(6), 16. Washington, DC: Author.

American Nurses Association (2006) House of Delegates Resolution. Workplace abuse and harassment of nurses. Retrieved from http://www.nursingworld.org/MemberCenterCategories/ANAGovernance/HODArchives/2006HOD/ActionsAdopted.aspx

American Nurses Association (2010) House of Delegates Resolution. Hostility, abuse and bullying in the workplace. Retrieved from http://www.nursingworld.org/MemberCenterCategories/ANAGovernance/HODArchives/2010-HOD/2010-Actions-Adopted/Hostilty.aspx

American Psychiatric Nurses Association. (2008). Position statements: Workplace violence.
Retrieved from http://www.apna.org/files/public/APNA_Workplace_Violence_Position_Paper.pdf

American Psychiatric Association. (2011). Healthy minds. Healthy Lives. Posttraumatic stress disorder. Retrieved from
http://www.healthyminds.org/Main-Topic/Posttraumtic-Stress-Disorder.aspx

Center for Disease Prevention and Control. National Institute for Occupational Safety and Health (2002). Violence: Occupational hazards in hospitals (NIOSH Publication No. 2002-101). Washington, DC: Department of Health and Human Services.

ECRI. (2005). Healthcare risk control system. Violence in healthcare facilities. Retrieved from
http://www.fha.org/acrobat/JohnW/ViolenceinHealthcareFacilities.pdf

Gallant-Roman, M. A. (2008). Ensuring nurses’ safety in violent workplaces. American Association of 
Occupational Health Nurses Journal, 56(2), 51-52.

Gallant-Roman, M. A. (2008a). Strategies and tools to reduce workplace violence. American Association of Occupational Health Nurses Journal, 56(11), 449-454.

International Council of Nurses. (2004). Guidelines on coping with violence in the workplace. Geneva, Switzerland: Author. Retrieved from http://www.icn.ch/publications/guidelines/

Joint Commission. (2008). Behaviors that undermine a culture of safety. Retrieved from http://www.jointcommission.org/assets/1/18/SEA_40.PDF

King-Jones, M. (2011). Horizontal violence and the socialization of new nurses. Creative Nursing, 17(2), 80-86.doi:10.1891/1078-4535.17.2.80

Longo, J. (2010). Combating disruptive behaviors: Strategies to promote a healthy work environment. Online Journal of Issues in Nursing, 15(1), 3. Retrieved from EBSCOhost.

New York State Penal Law. (2010). Title H, Article 120, Assault and related offenses, §120.05, Assault in the second degree.

Occupational Safety and Health Administration (OSHA). (2004). Guidelines for preventing workplace violence for health care & social service workers (OSHA Publication No. 3148-01R). Washington, DC: U.S. Department of Labor.

Occupational Safety and Health Administration. (2011). Hospital eTool: Administration. Retrieved from http://www.osha.gov/SLTC/etools/hospital/admin/admin.html#Recordkeeping

Olender-Russo, L. (2009). Reversing a bullying culture. RN, 72(8), 26-29.

Opie, T., Lenthall, S., Dollard, M., Wakerman, J., MacLeod, M., Knight, S., Dunn, S., & Rickard, G. (2010). Trends in workplace violence in the remote area nursing workforce. Australian Journal of Advanced Nursing, 27(4), 18-23.

Pontus, C. & Scherrer, D. (2011). Is it lateral violence, bullying or workplace harassment? Often, it is one and the same. Massachusetts Nurse, 16-17.

Qureshi, S. U., Pyne, J. M., Magruder, K. M., Schulz, P. E., & Kunik, M. E. (2009). The link between post-traumatic stress disorder and physical comorbidities: A systematic review. Psychiatric Quarterly, 80, 87-97.

Sellers, K., Millenbach, L., Kovach, N., & Yingling, J. K. (2009-10). The prevalence of horizontal violence in New York State registered nurses. Journal of the New York State Nurses Association, 40(2), 20-25. 
Thomas, S. P. & Burk, R. (2009). Junior nursing students’ experience of vertical violence during clinical rotations. Nursing Outlook, 57, 226-231. Doi:10.1016/j.outlook.2008.08.004

U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health. (2006). Workplace violence prevention strategies and research needs (Publication No. 2006-144). Retrieved from http://www.cdc.gov/niosh/docs/2006-144/

Weinand, M. R. (2010). Horizontal violence in nursing: history, impact, and solution. JOCEPS: The Journal of Chi Eta Phi Sorority, 54(1), 23-26. Retrieved from EBSCOhost.

ATTACHMENT A

Definitions

• Abuse – “Abuse is behavior that humiliates, degrades, or otherwise indicates a lack of respect for the dignity and worth of an individual” (ICN, 2004).
• Horizontal Violence - Vessey, DeMarco, and Budin (2007) as cited in Sellers, Millenbach, Kovach, and Yingling define horizontal violence as "Repeated, offensive, abusive, intimidating, or insulting behavior, abuse of power, or unfair sanctions that makes recipients upset and feel humiliated, vulnerable, or threatened, creating stress and undermining their self-confidence” (p. 21).
• Physical assaults - “Attacks ranging from slapping and beating to rape, homicide, and the use of weapons such as firearms, bombs, or knives” (CDC, 2002, p. 1).
• Threats - “Expressions of intent to cause harm, including verbal threats, threatening body language, and written threats” (CDC, 2002, p. 1).
• Workplace Violence - “According to the National Institute for Occupational Safety and Health (NIOSH), workplace violence is an act of aggression directed toward persons at work or on duty and ranges from offensive or threatening language to homicide” (CDC, 2002, p. 1).

For more information on nursing practice, contact NYSNA's Education, Practice and Research Program at 518.782.9400, ext. 282 or by e-mail.