Fear in Nursing: The Heroes Perspective

Nursing is a high-risk profession. While achieving “hero” status during the COVID-19 pandemic, nurses have faced countless work-related risks throughout time. These risks include physical injury, exposure, and psychological harm, such as lateral violence, sexual harassment, racism, and discrimination (American Nurses Association [ANA], 2019; Grant, 2020; International Council of Nurses [ICN], 2023; Ross et al., 2019). Despite ongoing efforts to improve the clinical work environment, nurses are now less safe than in previous years (Byon et al., 2022; McKay et al., 2020). This article describes a study on fear in nursing conducted before the pandemic and relates findings to current fears and risks nurses face in the workplace.

Background

Work-related fear and safety risks in healthcare are evident in the lay and nursing literature. Fear has led to increased job strain, low perceived organizational justice, high psychological distress, and consequences in physical, psychological, and emotional health, work functioning, patient relationships and outcomes, quality of care, and social and financial impacts (Grant, 2020; ICN, 2023; Lanctot & Guay, 2014; Magnavita & Heponiemi, 2012; Perlo et al., 2017). Nurses’ work environments affect nursing care and patient outcomes and contribute to burnout, job dissatisfaction, and the intention to leave (Buchan & Catton, 2023; Lake et al., 2019). Recent news and regulatory reports indicate that the work environment for nurses has not improved. Workplace violence and a new trend of public violence against nurses have increased due to the COVID-19 pandemic (Aiken et al., 2018; Byon et al., 2022; Ford, 2020; Forgione, 2020). The International Council of Nurses (ICN) reported a global increase in violence with 1,172 attacks and threats against health workers in 2020 (ICN, 2021). The number is likely much higher due to lack of reporting (Byon et al., 2022).

Nurses’ work environments affect nursing care and patient outcomes and contribute to burnout, job dissatisfaction, and the intention to leave

Recently, the most publicized work-related fear is exposure to contagious diseases. Accounts of exposures to chemical/radiation and diseases such as Ebola, HIV, Hepatitis, influenza, SARS Co-V, and most recently SARS COV-2, (COVID-19) (Buchan & Catton, 2023; Chan et al., 2005; Chan et al., 2009; Cipriano, 2015; Grant, 2020) are reported in lay and professional outlets. Exposures have led to acute and potentially life-threatening consequences, including the deaths of nurses due to COVID-19. Nurses report increased fear of spreading the disease to patients and family members (ANA, 2020b; Gelinas, 2020), mainly due to a lack of Personal Protective Equipment (PPE). Nurses have also been reprimanded and fired for voicing their concerns over unsafe conditions (Weber, 2020). Nurses report leaving their position due to the fear of contracting the virus or causing illness to their family (ANA, 2020b). In the most recent pandemic of COVID-19, over 115,000 healthcare workers worldwide died from this exposure (ICN, 2021a; World Health Organization, 2021). In the US, at the end of 2020, one-third of the over 3,000 healthcare workers who died of COVID-19 were nurses (Kaiser Family Foundation, 2020).

Additionally, healthcare workers face a violence epidemic, and intentional injuries have increased by 50% between 2011 and 2017 (Dressner & Kissinger, 2018; McKay et al., 2020). Twenty-five percent of nurses are assaulted in the workplace, with violent episodes increasing in public (Byon et al., 2022; Gilroy, 2020; Trossman, 2019; White, 2020). Workplace exposure to violence and contagious diseases have negative consequences, including emotional distress, decreased self-confidence and esteem, injury, or death (Grant, 2020). These factors may lead to physical symptoms, including sleep disturbances, neurological changes, psychological symptoms, gastrointestinal symptoms, posttraumatic stress disorder, or suicide (DePuy et al., 2013; Gelinas, 2020; Melynk, 2020; Moore, 2020).

Workplace exposure to violence and contagious diseases have negative consequences, including emotional distress, decreased self-confidence and esteem, injury, or death

Compounding this issue is nurses’ underreporting of violence, citing fear, or feeling unsafe in communicating problems to the administration (Byon et al., 2022; Locke et al., 2018; Nowrouzi-Kia, 2017; Sherman & Blum, 2019; Toon et al., 2019). According to the ANA, 77% of nurses who sustained injuries did not report the incident (ANA, 2018; ANA, 2019). Reporting rates vary from 20 to 60 percent of nurses who experience violence (ANA, 2018; ANA, 2019).

Safety risks significantly impact the nursing workforce. COVID-19 increased nursing workload, traumatization from rapidly shifting work environments, and caring for critically ill patients, leading to a mass exodus from the workforce with the loss of more than 100,000 of the total supply of RNs in the United States (Auerbach et al., 2022; ICN, 2021b). The global nurse shortage increased to over 30 million nurses in the aftermath of the crisis (Haakenstad et al., 2022). Retention rates are staggering; one-year retention rates for newly licensed RNs are at 83%, with 33.5% leaving within the first two years in addition to a 15.9% turnover rate for bedside RNs (Kovner et al., 2014, NSI, 2020). Additionally, there has been a drop in applications for admission into Bachelor of Nursing programs, and a decline in enrollment in all nursing program levels (Ammerican Association of Colleges of Nursing, 2023; Auerbach et al., 2022). The fear that results from exposure and violence may have financial costs to the healthcare organization due to lost time and productivity, worker’s compensation, litigation, and the cost of negative publicity (ANA, 2018; Papa & Venella, 2013).

This article aims to report the results of a study conducted to identify situations that invoke work-related fear associated with nursing practice. While not all negative situations elicit fear, some critical and unreported situations may exist without leaders' and administrators’ knowledge. For this reason, a survey was developed to assist leaders and other nurses in learning more about these organizational situations.

Conceptual framework

This study defines fear as “a distressing emotion aroused by impending danger, whether the threat is real or imagined, the feeling or condition of being afraid” (Dictionary.com, 2011). Four areas of fear were conceptualized during the instrument’s development and revealed in the analysis.

Table 1. Operational Definitions of Fear

Purpose

This study aimed to measure the degree to which nurses identify fear associated with 20 situations identified in nursing literature. The relationship between fear associated with work and 12 demographic characteristics and qualitative comments were evaluated. As nurses do not routinely report incidences and situations that cause fear and injuries, using a questionnaire allows them to identify situations where they do not feel safe without concerns of retaliation by their organization (ANA, 2019; Grant, 2020; Locke et al., 2019; Nowrouzi-Kia, 2019; Sherman & Blum, 2019; Toon et al., 2019).

Methods

This mixed methods, cross-sectional survey study was conducted at a for-profit university with 11 campus-based programs and an online program across the United States of America (USA). University Institutional Review Board approval was obtained. The Fear in Nursing Questionnaire consisted of 20 items using a four-point Likert-type scale ranging from strongly disagree to strongly agree and three qualitative questions. Higher scores indicate the subject identified more fear. There were 424 nurse respondents. After removing incomplete surveys, 413 cases were used for data analysis.

Results

The Cronbach’s α coefficient was used to measure the internal consistency reliability of the questionnaire. The Cronbach’s α coefficient overall result was .909; for the subscales, the results were fear of physical/personal harm .804, fear of the healthcare environment .781, fear of psychological harm .791, and fear of patient harm .696. Interestingly, the primary fear of nurses was “the administration in the organization where I work will not protect me,” with 65% responding with “agree or strongly agree” (mean 2.82). This was followed by “I have a fear that I will not be able to meet the needs of my patients in the time I have available during my shift” (mean 2.59 - 51%) and “I have a fear of being sued or being involved in litigation” (mean 2.56 - 57%).

Table 2. The Greatest to Least Fears

Other significant findings in relation to fear were the correlation between fear of physical/personal harm (p=.001), fear of the health care environment (p=.001) and fear of patient care (p=.001) associated with hours worked. Nurses who worked over 9 hours had a significant increase in fears in relation to these 3 areas with a maximum noted fear at working over 12-hours. Staff nurses reported more fears of physical/personal harm, patient care, and the healthcare environment compared to other positions. Nurses who worked night shift reported more fear associated with the healthcare environment followed closely by nurses who worked evening shift.

Additionally, there was a significant relationship between fear of physical/personal harm, healthcare environment, and patient care in relation to time as a registered nurse. Interestingly, in relation to fear of physical/personal harm, nurses with 5-10 years in practice had the highest level of fear, and nurses with less than two years reported a slight decrease. Nurses with over ten years in practice reported less fear of physical harm, with the lowest reported fear at 31 years or more in practice.

One hundred seventeen nurses responded to the question, “Are there any other fears you can identify associated with your work as a nurse?” They identified age and race discrimination, sexual harassment and assault, and retaliation. In response to the question, “Describe a recent situation that caused you fear or to be afraid associated with your work,” 46 nurses described incidents related to physical harm and aggressive patients, family members, or peers. Other themes related to physical harm were exposure, patient handling, sexual assault, and stalking. Concerning psychological harm, bullying, retaliation, and moral distress were reported. Other issues related to the healthcare environment were a lack of resources, staffing, and training.

Discussion

The most significant finding was that 65% of nurses in this study said they fear the administration in their work organization will not protect them. This fear is related to the healthcare environment that is increasingly volatile, uncertain, complex, and ambiguous (Sherman & Blum, 2019). Unintended consequences of this complexity put nurses in unsafe positions despite efforts to improve work environments. Aiken et al. (2018) found that even with work environment initiatives, between 2005 and 2016, only 21% of the hospitals showed improvement, whereas 7% experienced environmental decline. Similarly, Sherman & Blum (2019) described the deterioration in healthcare work environments due to complexity. Reliance on performance measures and the subsequent impact on reimbursement and regulation on the organization adds added pressure to nurses working in complex environments.

Staffing and workload issues are global healthcare problems. Cornwall (2018) reported that 91% of nurses felt their hospital was understaffed. In this same study, 54 % reported that their workload had negatively impacted their mental health (Cornwall, 2018). In addition, 62% of nurses reported that the nursing shortage impacted the quality of care they provided their patients (Cornwall, 2018). This finding was evident even before the lack of PPE during the COVID-19 pandemic. In a March and April 2020 survey, 87% of nurses reported being afraid to return to work due to a lack of PPE. The ability to protect nurses is a systemic problem. In this survey, 68% of nurses were worried about being short-staffed (ANA, 2020b). National and international reports of a staffing crisis and a nurse shortage that leads to burnout, moral suffering and leaving the profession point to policy decisions before the pandemic as a cause of the crisis (Buchan & Catton, 2023; ICN, 2023; Johnstone, 2022; Schlak et al., 2022). The health care system and organizations' lack of adequate resources and staffing, coupled with the litigious society in the US, has created an atmosphere in which nurses fear litigation. Consequences of this may include economic impacts and affect licensure, present position, and ability to find future work. Additionally, nurses may leave the profession after being involved in litigation (Hood et al., 2010; Pensa, 2023).

Nurses working the night shift and those working more than 12 hours reported increased fear compared to other nurses. These findings relate to staffing, supervision, workload, and the provision of adequate resources, which can affect nurse surveillance and patient outcomes. Melnyk et al. (2018) found that 12-hour shifts inversely affect nurses' physical and mental health and worksite wellness and increase medical errors. Subsequently, Melnyk (2020) called for 12-hour shifts to be eliminated because of the negative impact on nurses’ health and patient care. Furthermore, a 2017 systematic review of the impact of 12-hour shifts on nurses’ health, well-being, and job satisfaction suggested that 12-hour shifts resulted in adverse health concerns and job dissatisfaction (Banakhar, 2017). As one study participant stated, “Nurses are stretched beyond belief. We go home not only physically exhausted but mentally exhausted…and who is taking care of us?” Increased shifts beyond 9 hours have been associated with job dissatisfaction, burnout, and intent to leave (Dall'Ora et al., 2022).

Fear of physical/personal harm was highest in nurses with 5-10 years of experience. Personal or bystander experiences of violence, physical injury, workplace exposures, and institutional factors may support this finding (McKay et al., 2020). Nurses with more experience may have additional responsibilities as charge nurses, mentors, or preceptors, which may increase fear. In this study, nurses reported that additional fears should be added to the questionnaire reflecting recent events and cultural changes. Rising assaults on healthcare workers worldwide during the pandemic brought the issue into the lay and professional literature (McKay et al., 2020). Sexual assault, sexual harassment, and racial discrimination were identified in this survey even before societal events brought these issues to the forefront of US culture. These questions will be added to subsequent versions of this questionnaire.

Fear of physical/personal harm was highest in nurses with 5-10 years of experience.

Protection for nurses can be designed using the IHI Framework for Joy in Work to create organizational change (Perlo et al., 2017). The first step is for leaders to understand what fears nurses want to address specific to their institution or unit. Next, leaders elicit information from the nurses on what impedes joy within their employment. Finally, it is essential to use a systems approach to change the institutional priority to implement new methodologies and evaluate the intervention's functionality (Perlo et al., 2017). For example, UVA Health implemented a program utilizing a systems approach by applying the IHI Framework for Joy, which addressed well-being as a value, eliminating work stressors, establishing a Chief Wellness Officer, patient safety, self-care, and partnership formation with accrediting organizations (Cipriano, 2021). Institute for Healthcare Improvement (2020) disseminated a guide to support staff wellbeing and joy in work during and after the COVID-19 pandemic. Involvement in policy change at the organizational, local, state, federal and global levels is imperative to protecting nurses and improving the work environment (Buchan & Catton, 2023; ICN, 2023; Schlak, et al., 2022)

Limitations

As in all studies, there are limitations related to this study. The response to the survey was voluntary and anonymous, therefore, those who responded may not be representative of the population. There was no opportunity for follow-up with the participants. The survey was only sent to RNs who attended a for-profit university in the United States of America (US). The influence of education and this institution on this sample may have influenced their responses, affecting generalizability to other populations, and the responses cannot be generalized to other nations. The study was conducted before the COVID-19 pandemic; if completed after the pandemic, there might be very different responses. However, the study did uncover many fears that nurses had related to the healthcare system and their organizations.

Implications for Practice

Nurses and healthcare administrators must be aware of the many perceived dangers that nursing staff may have as they work in the organization. Developing a healthcare system that is prepared to protect and support staff is imperative to quality and to reduce costs, as the financial consequences of loss of productivity, increased turnover, and litigation can be substantial (Buchan & Catton, 2023; Konetzka et al., 2018; Lanctot & Guay, 2014). Creating a culture of preparedness, support, and protection for healthcare workers is critical in all areas of nursing. Fears related to the work environment will differ for each unit, organization, and state. Nurses and healthcare organizations must identify and assess these fears to create a supportive and safe environment and foster resilience within the organization or healthcare system (McMillian, 2020). A safe work environment is based on a culture of ethical behaviors and respect (ANA, 2020d; Locke et al., 2019; Perlo et al., 2017). Nurses in leadership, management, and academic positions must be aware of the many perceived dangers that nursing staff may have as they work in the organization.

...a healthcare system that is prepared to protect and support staff is imperative to quality...

With the most fear identified in those working 12 hours or more, a change in staffing decisions and resource allocation is needed. Creative staffing may require multiple options, including 4, 6, or 8 and 10-hour shifts, and should be researched to meet specific unit requirements. Moreover, support of nurses during the night shift is warranted. Minimal leadership, management, and administrative coverage can allow for bullying, unfair assignments, and a lack of supportive services. Administration efforts must increase supervision and sustain safe environments during these hours. Nursing workload and better use of nurses’ skills are essential for the administration to consider.

Nationally, support of the ANA, and other organizations working on work environment issues is critical. The ANA issue brief “Reporting Incidents of Workplace Violence” (2019) states that creating a culture of safety is an ethical imperative for all leaders. Their goal is to increase the reporting of workplace violence. In the US, there is no standardized reporting process for incidences of workplace violence. Even though the Joint Commission identifies assault as a sentinel event, the reporting is voluntary (ANA, 2021). Global, national, and state legislative efforts and the #End Nurse Abuse campaign by ANA are examples of the important ongoing work on this issue. Support of these efforts and increased involvement is critical.

Our results revealed that racism and discrimination in healthcare organizations cause fear in ethnic minority nurses. Programs exist but must be expanded to address institutional racism and discrimination, including educating nurses to interact with a diverse population (Inhedura-Anderson & Waite, 2021). In addition, ANA has set a goal to address structural discrimination (Stand, 2020). These measures provided by the ANA encompass a pledge of each of its members to oppose and address racism and discrimination, condemn brutality, recognize human dignity, partner with other organizations to educate, advocate and collaborate to end racism, advance legislation to promote diversity, inclusion, equity and social justice, advocate on ending healthcare inequalities and promoting a respectful and deliberate dialogue as a means of improving the health of all individuals and communities (ANA, 2020c). Uncovering safety threats is an important step in identifying and implementing this change.

Future Research

Since the COVID-19 pandemic, studies on the lingering effects of a lack of PPE, failure of organizational responses to the crisis, healthcare worker support, community perception of nurses “from heroes to villains” and the fear it created should be investigated. The findings from this study reveal that more research is needed in the areas of discrimination, workplace violence including sexual harassment and abuse, and work environment related to fear. Research relating to fear after violent incidents across specialties and organizational structures should be conducted.

As such, it would be interesting to measure fear in relation to Magnet® and non-Magnet® organizations. Nurses, partnering with other disciplines, such as ergonomics, environmental design, and health information technology, could examine workflow and redesign nursing care processes to improve those processes and mitigate fears. Studies on the results of nurses’ fear, mental and physical health, and patient outcomes after eliminating 12-hour shifts are necessary.

Conclusion

This study identified many fears nurses face and the relationships between these fears and demographic and work factors. While the study was completed before COVID-19, the most concerning finding was that most nurses in this study endorsed fears of lack of protection by administrators. Surprisingly, the fear of physical/personal harm was highest in RNs working for 5 to 10 years. This questionnaire may be helpful to assess fears that are unreported due to concerns of retaliation and to develop appropriate interventions. Protection and support of nurses must be the driving goals of the profession and healthcare organizations in the US.

Authors

Virginia Pesata, DNP, APRN, FNP-BC, FNAP
Email: vpesata@gmail.com
ORCID ID: https://orcid.org/0000-0002-4028-6459

Dr. Virginia Pesata is an adjunct nursing faculty at Colorado Technical University and a research scholar at the University of Florida, Center of Arts in Medicine. She earned a Doctor of Nursing Practice degree and two Master of Nursing degrees as a Family Nurse Practitioner and Pediatric Nurse Practitioner. She has worked at all levels of nursing as a nursing assistant, licensed practical nurse, registered nurse, pediatric and family nurse practitioner, nursing administrator, research scholar, nursing faculty, and program director. She has worked in several settings in home health, community hospitals, academic medical centers, and universities. Her broad background in nursing and in multiple settings fostered an interest in researching the concept of fear related to nursing practice.

Rose Nieves, PhD, ARNP, FNP-c, CNE
Email: rnieves@coloradotech.edu
ORCID ID: https://orcid.org/0000-0001-9828-8871

Dr. Rose Nieves is the Dean/Chief Nursing Officer at Colorado Technical University, College of Nursing. at Colorado Technical University. Her work in direct patient care, education and administration has provided her with a front-line perspective on the issues related to fears that nurses face in clinical practice before and during the nursing pandemic. She has worked at the national level in establishing and ensuring standards of nursing excellence in education along with working to support and advocate for the minority nurse.