Preventing Workplace Violence in Healthcare

The problem of physical violence against healthcare workers is a weed with deep roots that just keeps growing. Nearly every experienced nurse has a story about aggressive or unwanted physical contact from a patient or someone connected with a patient. Too often, nurses suffer cuts, bruises, sprains, fractures, head injuries, internal injuries, suffocation and even death during the course of patient care.

The Challenge

Despite increased awareness and efforts to mitigate violence in healthcare, data from the U.S. Bureau of Labor Statistics (BLS) indicates the problem has increased over time. Statistics on private healthcare and social assistance industry workers show that violent incidents rose from 6.4 per 10,000 in 2011 to 10.4 per 10,000 in 2018.

Looking specifically at nurses, a 2016 BLS report shows that violent events accounted for 12.2% of all injuries to registered nurses (RNs) in 2016. The RN rate of 12.7 violent events per 10,000 full-time workers is about three times greater than for all occupations (3.8 cases per 10,000 workers).

Part of the challenge is that government reporting lags by years and not all incidents are reported, so those working to solve the problem don’t have a clear picture of what’s actually happening. Unfortunately, no matter what year the data is collected, hospitals consistently stand out as some of the most dangerous workplaces in the country.

The lack of reporting is a serious barrier to effective research and regulatory or legal action. Here are three reasons commonly given for not reporting violent incidents:

• Fear of retaliation
• Lack of a clear reporting method
• Belief that nothing will be done about it

The belief that “nothing will be done” is not unfounded. California has some of the most detailed healthcare safety standards in the country. The state requires strict reporting, yet a San Francisco news station’s investigative report shows that nothing was done in 76% of violent incidents reported to Cal/OSHA because there was “no continuing threat.” There is no reason to think that California healthcare institutions are unique in this approach. This needs to change.

Do Something!

It’s in everyone’s interest to solve this problem. Nurses want to practice without the danger of assault, and it’s costly for hospitals to replace nurses who leave due to injury or because they are simply fed up.

According to the 2021 National Healthcare Retention & RN Staffing Report, “the average cost of turnover for a bedside RN is $40,038 and ranges from $28,400 to $51,700 resulting in the average hospital losing between $3.6 million to $6.5 million per year. Each percent change in RN turnover will cost/save the average hospital an additional $270,800 per year.” This may be one reason the American Hospital Association promotes an annual Hospitals Against Violence Day (#HAVHope).

A problem this complicated and enduring needs to be examined at every level — from the halls of Congress to those of your own unit. No one has discovered the ultimate fix, but a lot of people are working on it.

Federal Legislation

In early 2021, the U.S. House of Representatives passed H.R. 1195, the Workplace Violence Prevention for Health Care and Social Workers Act. It passed with bipartisan support and is now in review by the Senate Committee on Health, Education, Labor and Pensions. Among other measures, the bill requires the Occupational Safety and Health Administration (OSHA) to create enforceable safety standards by 2025.

• AACN joined with the Nursing Community Coalition to support this House bill. Many elements of the bill align with AACN’s position statement on “Preventing Violence Against Healthcare Workers” and support our healthy work environments initiative.
• The American Hospital Association opposes this bill and argues that new OSHA standards are unwarranted, because hospitals have already implemented specifically tailored policies and programs to address workplace violence. They also assert the bill’s mandates would create costs that would strain hospitals in rural and underserved communities.

State Legislation

The American Nurses Association’s Workplace Violence webpage lists what different states have done to support the safety of healthcare workers. These actions include:

• Establishing or enhancing penalties for assaults on nurses
• Allowing healthcare workers to use only first names on identification badges
• Requiring employer-run workplace violence prevention programs

Healthcare Institutions

Most hospitals have instituted some measures against violence, but there is much more work to do. A 2020 systematic review in Journal of Advanced Nursing, “Workplace Violence Against Nurses and the Role of Human Resource Management,” (HRM) concludes that hospital HRM worldwide lacks methodical and effective practices to prevent violence in the workplace and mitigate its effects on nurses’ mental health. This study also points to a lack of available research in healthcare-specific HRM literature to establish effective institutional interventions.

AACN’s position statement “Preventing Violence Against Healthcare Workers” urges hospitals to do the following:

• Educate staff on how to recognize the potential for violence, how to employ de-escalation techniques, and how to seek assistance to prevent or respond to violence.
• Establish a clear and consistent reporting structure for workplace violence, with easy to understand policies and procedures on how to report violent incidents to law enforcement.
• Encourage employees to press charges against persons who assault healthcare workers, and support staff members who do.
• Provide resources and support programs for employees to help them cope with violent incidents.
• Evaluate staffing and patient classification systems that could increase or reduce the risk of violence.
• Ensure the presence of sufficient security systems, including alarms, emergency response and available security personnel.

Nurses

AACN maintains that it is ultimately healthcare institutions’ responsibility to prevent workplace violence. Still, there are some things you can do:

• Participate in educational training on violence awareness and prevention.
• Learn and maintain your knowledge of your hospital’s safety policies, procedures and crisis plans.
• Report it! Speak up if you experience an incident or witness violence against someone else.
• Press charges if you are assaulted.
• Support co-workers who experience violence.
• Seek solutions as a team.

Learn More

There are many more resources such as webinars, journal content and recordings from past NTIs available on AACN’s website. Here are three places to start:

• A webinar on self-protection, “Protect Yourself: Prepare for and Prevent Workplace Violence”
• AACN’s research on the health of nurses’ work environments, “Critical Care Nurse Work Environments 2018: Findings and Implications”
• AACN’s foundational guide to healthy work environments, “AACN Standards for Establishing and Sustaining Healthy Work Environments”

Nursing associations and healthcare agencies also have useful information on the prevention of healthcare workplace violence. Here are a few examples:

• American Hospital Association, Hospitals Against Violence
• The Joint Commission, Workplace Violence Prevention Resources
• ECRI, “Violence in Healthcare Facilities”
• American Nurses Association, “Violence, Incivility, & Bullying”

The U.S. government has information and statistics that can help with both prevention and advocacy on this topic. These sites are helpful:

• U.S. Department of Labor, Occupational Safety and Health Administration, Worker Safety in Hospitals: Caring for our Caregivers
• U.S. Bureau of Labor Statistics, Fact Sheet: Workplace Violence in Healthcare, 2018
• National Institute for Occupational Safety and Health, “Workplace Violence Prevention for Nurses”

What are your suggestions to prevent violence in healthcare?