INTENT

The intent of this position statement is to promote violence prevention in the health care setting using consolidated approaches from employers, victims, and the political system.

POSITION

• Violence should never be considered “part of the job.”

• While there are predisposing reasons why violence is on the rise in health care settings, such as lack of access to mental health care, substance abuse, and long wait times for care due to understaffing, facilities must make every effort to ensure the safety of both staff and patients. 

• Violence can take many forms and may include, but not be limited to: assaults, verbal threats, disruptive and abusive behavior, sexual abuse, stalking, active shooter situations and domestic violence that enters the workplace.

• The employer must proactively address all forms of violence, whether the perpetrator is a patient, visitor or staff person, regardless of the mental and/or physical competency of the perpetrator.

• Each health care sector employer must establish, implement, and maintain an effective written workplace violence prevention plan using appropriate engineering and work practice/administrative controls that are in effect at all times and are specific to the hazards and corrective measures for each unit, service, or operation.

• Each written workplace violence prevention plan must address patient-related specific risk factors and include appropriate policies and procedures for dealing with such risk factors.

• Each health care employer must proactively and continuously assess all areas in which health care services or operations are conducted for environmental risk factors that may contribute to the likelihood or severity of a workplace violence incident.

• The political system (law enforcers, regulatory agencies, courts, etc.) must proactively address all forms of violence in the health care setting, whether the perpetrator is a patient, visitor, or staff person, regardless of whether that person has a mental or physical disorder that might affect the competence of that person.

• Private sector health care institutions should be regulated by an enforceable statutory workplace violence standard such as public sector institutions in New York State are.

BACKGROUND 

The health care sector makes up just 9 percent of the overall U.S. workforce. Nevertheless, according to the U.S. Bureau of Labor Statistics, the Occupational Health Administration (OSHA) and the U.S. Department of Justice’s National Crime Victimization Survey, the health care sector experiences more incidents of violence than any other industry (OSHA, 2016).

While violent incidents have traditionally been more common in psychiatric units, emergency departments and geriatric units, violence has now become increasingly common in all parts of health care facilities and in homecare settings as well. The numbers of incidents of violence in the health care setting continues to rise, creating a non-therapeutic environment for patients and a safety risk to both patients and staff in all specialty units (Potera, 2016).

U.S. Bureau of Labor Statistics data indicates that a worker in health care and social assistance settings is nearly five times more likely to be the victim of a nonfatal assault or violent act by another person than the average worker in all other major industries combined.  In 2011, the incidence rate of violence and other injuries by persons in the private health and social assistance sector was more than triple the overall rate for all of private industry (U.S. Bureau of Labor Statistics, 2012). Between 2005 and 2014, the rate of health care workplace violence increased by 110 percent in private-sector hospitals (U.S. Bureau of Labor Statistics).  In 2014, three in four nurses experienced verbal or physical abuse—such as yelling, cursing, grabbing, scratching or kicking—from patients and visitors, according to one study (Gabel-Speroni, et. al. 2014).

Nurses are especially vulnerable to violence in the workplace because they are the largest sector of the health care workforce, spend more time with patients than other health care providers, and interact with almost all patients and visitors who come through the door—regardless of their condition. Workplace violence prevention plans, training, reporting and recordkeeping and reporting of violent incidents to law enforcement agencies, therefore, are key to the reduction of incidents of violence against nurses in the health care setting.

The problem has become so severe that the Joint Commission, which primarily focuses of patient safety, has issued a Sentinel Even Alert regarding actions health care institutions should take to protect health care workers from violence (Joint Commission, 2018). These actions include:

• improved incident reporting mechanisms;
• incident data tracking and analysis;
• post-incident support;
• incident investigation and analysis;
• quality improvement initiatives to reduce incidents;
• staff training;
• evaluation of workplace violence reduction initiatives.

For many years the New York State Nurses Association has advocated on the facility, city, state and federal level for actions to protect health care workers against workplace violence. One result of this advocacy was the 2010 amendment to the New York State Penal Code (Subdivision 3 of Section 120.05) that allows felony charges to be brought against assailants who assault nurses on the job, instead of misdemeanor charges. The New York State Nurses Association supports nurses who choose to file charges against assailants. While obtaining a felony charge against an assailant can be a difficult process, nurses must continue to report such incidences to law enforcement agencies. In addition, the NYSNA believes that all employers should create and implement a policy and process with instruction on how to report violent incidents to law enforcement officials and should provide ongoing support to victims of violence during this process.

Another victory for the New York State Nurses Association and other New York State unions includes the New York State Department of Labor Public Employee Safety and Health Bureau (PESH) Public Employer Workplace Violence Prevention Programs Regulation (12 NYCRR Part 800.6) promulgated in 2007. This regulation requires that public sector employers in New York State:

• Develop and implement a workplace violence prevention policy statement and workplace violence prevention program;
• Conduct a risk evaluation and determine what risk factors are present and implement controls to decrease the identified risks;
• Provide information and training to employees on workplace violence;
• Develop a system to record workplace violence incidents and maintain those records. 

The New York State Nurses Association continues to advocate for a workplace violence prevention regulation that would provide similar protection to private sector health care workers.

DEFINITIONS 

For the purposes of this position statement, the following definitions are offered:

Workplace violence is defined as any act of violence or threat of violence, that occurs wherever an employee is conducting his or her job and includes: (A) the threat or use of physical force against an employee by a patient, a person accompanying a patient, other employees, or other person that results in, or has a high likelihood of resulting in, injury regardless of whether the employee sustains an injury; (B) an incident involving the threat or use of a firearm or other dangerous weapon including the use of common objects as weapons, regardless of whether the employee sustains an injury; (C) stalking and unwanted sexual contact.

Violence threat is defined as any oral or written expression or gesture that could be interpreted by a reasonable person as conveying an intent to cause physical harm to persons or property.

Disruptive behavior is defined as any behavior that shows disrespect for others, or any interpersonal interaction that impedes the delivery of patient care (AHRQ, 2017). Disruptive behaviors, which can include horizontal/lateral abuse (co-worker to co-worker) and vertical abuse (supervisor to subordinate), contribute to an unhealthy workplace as well as increase the potential for medical errors. Environments where this type of behavior is tolerated by facility leadership have increased staff turnover and higher absenteeism (Joint Commission, 2008; Longo, 2010; Weinand, 2010). The problem is so significant that the Joint Commission issued a Sentinel Event Alert in 2008 called “Behaviors that undermine a culture of safety Joint Commission, 2008). The alert recommends that health care 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;
• Conduct assessments, interventions and document follow through.

Code of conduct is defined as an organization's expectations and guiding principles for appropriate workplace behavior. The Joint Commission now requires health care facilities to have a code of conduct that defines acceptable as opposed to disruptive and inappropriate behaviors. Also required is that facility leadership create and implement a process for managing disruptive and inappropriate behaviors (JC Standard LD.03.01.01 EP 4&5).

The New York State Nurses Association believes that, in order to maintain a safe workplace for both patients and staff, health care facilities must enforce the code of conduct uniformly. No employees, because of their specific job title or profession, should be allowed to behave in a way that violates the code of conduct.

Felony assault, under NYS Penal Law, Section 1201.05(3),is defined as a perpetrators’ intent to prevent an RN from performing an essential service or performing a duty, and as a result, causes a physical injury to such RN. Physical injury is defined as an impairment of physical condition or substantial pain (NYS Penal Law, Section 10).

Engineering controls are defined as physical changes to the workplace that either remove a hazard from the workplace or create a barrier between the worker and the hazard. Engineering controls include, but are not limited to:  electronic access controls to employee occupied areas, weapon detectors (installed or handheld), enclosed workstations with shatter-resistant glass, deep service counters, separate rooms or areas for high risk patients, locks on doors, furniture affixed to the floor, windows in patient rooms and all offices to minimize health care worker isolation, closed-circuit television monitoring and video recording, sight-aids, and personal alarm devices.  Engineering controls should be the initial choice for workplace violence prevention.

Work practice/administrative controls are defined as policies, procedures, training, staffing, etc. that are used to effectively reduce workplace violence hazards. Administrative controls include, but are not limited to:  appropriate staffing levels, provision of dedicated safety personnel (i.e. security guards), employee training on workplace violence prevention methods, crisis response team development and training, improved communication systems to decrease frustration and agitation, staff required to wear IDs, patient and visitor sign in system when entering facility, electronic medical record flagging system, limit employees working alone, reasonable visitation policies, field work/home visit safety protocols and employee training on procedures to follow in the event of a workplace violence incident. Work practice/administrative controls should be the secondary choice for workplace violence prevention and used in conjunction with engineering controls.

Environmental risk factors are defined as conditions in an area where health care services or operations are conducted that may contribute to the likelihood or severity of a workplace violence incident. The intent of this definition is to compel employers to assess areas where employees work within a facility, in areas associated with the facility such as parking lots, and in areas where field operations are conducted, for potential exposures to violence. This allows employers to inform the employees at risk and implement appropriate protective measures.

Patient-related specific risk factors are defined as factors specific to a patient, such as use of drugs or alcohol, psychiatric condition or diagnosis, any condition or disease process that would cause confusion and/or disorientation or history of violence, which may increase the likelihood or severity of a workplace violence incident.

RECOMMENDATIONS

The New York State Nurses Association believes that prevention is key to decreasing incidents of workplace violence. While it is not possible to eliminate all risk of violence, steps can, and must, be taken to decrease the risk of violence occurring in the health care setting. In order to decrease the risk of violence, health care facilities must:

• Conduct a full facility risk assessment with front-line worker (if represented by a union, union member designee) input to identify where and what type of violence risk factors exist. A risk assessment should also be conducted for all employees who work outside of the facility, such as home care providers. Risks assessments should include:
• On-site environmental inspections
• Data analysis including injury and illness logs, incident reports and workers’ compensation claims
• Assessment of mitigation actions
• Put in place engineering and work practice/administrative controls that limit the risk of violence including, but not limited to, physical barriers, access controls and personal alarm systems;
• Review and amend policies and procedures that may put staff at risk of assault;
• Improve staffing levels to decrease wait times and increase patient oversight;
• Provide adequate numbers of well-trained security personnel;
• Create and train crisis management teams to respond to violent and potentially violent situations;
• Develop a system to improve reporting of workplace violence incidents without fear of retaliation;
• Create a written workplace violence prevention program, with front-line worker (if represented by a union, union member designee) input, that includes a definition of workplace violence, information on identified risks and control measures put in place to remediate risks, and reporting and recordkeeping procedures;
• Provide training to all staff on topics including, but not limited to, the workplace violence prevention program, identified violence hazards and controls, reporting procedures and de-escalation skills;
• Develop a procedure to notify union representatives (if represented by a union) of violent incidents in a timely manner and conduct a root cause investigation of these incidents;
• Develop a procedure to review workplace violence incidents and assess the effectiveness of the workplace violence prevention program with front-line worker (if represented by a union, union member designee) representatives;
• Create and implement a policy and process with instruction on how to report violent incidents to law enforcement.

Additional recommendations can be found from the following sources:

• Sentinel Event Alert Issue 59, Physical and verbal violence against health care workers, Joint Commission (2018)
• Guidelines for Preventing Workplace Violence for Healthcare and Social Service Workers, OSHA (2018)
• Violence:  Occupational Hazards in Hospitals, NIOSH (2002)

If you are represented by a union, notify your union representative if you or a colleague is the victim of workplace violence so that the union can take follow-up actions to prevent additional occurrences.

CONCLUSION

Registered professional nurses have a duty to advocate for a safe environment for both patients and fellow health care workers (Code of Ethics for Nurses, 2015). By organizing colleagues to advance the violence prevention recommendations highlighted in this policy statement, nurses can achieve a more secure, safe and therapeutic environment.

For further information, see related NYSNA position statements on gun violence, active shooter situations, sexual harassment and domestic violence.

RESOURCES

AHRQ. Agency for Healthcare Research Quality. (June, 2017).  Disruptive and unprofessional behavior. Retrieved on 5/3/2018  from https://psnet.ahrq.gov/primers/primer/15/disruptiveand- unprofessional-behavior.

American Nurses Association. (2015). Code of Ethics with Interpretive Statements.  MD: Author.

Gabel-Speroni, K, Fitch T., Dawson E., Dugan, L. Atherton, M. (May 2014). Incidence and cost of nurse workplace violence perpetrated by hospital patients or patient visitors. Journal of Emergency Nursing, 40 (3), 218-228.

Joint Commission. (April, 2018). Physical and verbal violence against health care workers. Sentinel Event Alert. 59. Retrieved on 5/3/2018 from https://www.jointcommission.org/assets/1/18/SEA_59_Workplace_violence_4_13_18_FINAL.pdf. Joint Commission (2017). Retrieved on 5/3/2018 from https://www.jointcommission.org/workplace_violence.aspx.

Joint Commission. (July, 2008). Behaviors that undermine a culture of safety. Sentinel Event Alert 40. Retrieved on 5/3/2018 from https://www.jointcommission.org/assets/1/18/SEA_40.PDF. Joint Commission. (2008). Joint Commission Standard LD.03.01.01 EP 4&5.

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.

National Institute for Occupational Safety and Health. (December, 2016). Workplace Violence

Prevention Course for Nurses, NIOSH Publication No. 2017-114.

New York Code of Rules and Regulations. 12 NYCRR Part 800.6.

New York State Department of Labor Public Employee Safety and Health Bureau (PESH).  Retrieved on 5/3/2018 from https://www.labor.ny.gov/workerprotection/safetyhealth/workplaceviolence.shtm.

New York State Penal Code Section 120.05 (3).

Occupational Safety and Health Administration. (2016). Guidelines for Preventing Workplace Violence for Healthcare and Social Service Workers, U.S. Department of Labor Occupational Safety and Health Administration.

Potera, C. (June, 2016). Violence against nurses in the workplace. The American Journal of Nursing. 116 (6), 20-21.

U.S. Bureau of Labor Statistics. (November, 2012).  Non fatal Occupational Injuries and Illnesses Requiring Days Away From Work. Retreived on 5/3/2018 from www.bls.gov/news.release/osh2.toc.htm.

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. Reviewed and revised on March 22, 2018.