OSHA describes workers who provide services, work in remote or high crime areas, and those who work shift hours and/or have a great deal of contact with the public as employees who are at a higher risk to encounter violence in the workplace. The United States Department of Labor, Occupational Safety and Health Administration (U.S. DOL OSHA) reports that over 2 million American workers are victims of workplace violence each year. Violence can strike any workplace; no area is immune. But who may be more at risk? OSHA (IMPACT, 2006-2007; U.S. DOL, 2002) describes workers who provide services, work in remote or high crime areas, and those who work shift hours and/or have a great deal of contact with the public as employees who are at a higher risk to encounter violence in the workplace. This group thus includes health care workers, such as nurses and other providers (both community- and hospital-based), social workers, and psychiatric evaluators.

What is workplace violence? You will find a multitude of definitions in the literature. The National Institute for Occupational Safety and Health (NIOSH) defines it as “violent acts (including physical assaults) directed toward persons at work or on duty” (Department of Health and Human Services [DHHS], 2002, p 1).Others use similar wording such as violence or the threat of violence against workers; acts of aggression or physical assault; threatening behaviors; or behavior that causes emotional or physical harm. Still others describe workplace violence as an act of aggression, physical assault, or threatening behavior that occurs in a work setting and causes physical or emotional harm to customers, coworkers, or managers (Anderson, 2002; DelBel, 2003; DHHS, 2002; Love & Morrison, 2003; McPhaul & Lipscomb, 2008). The common themes have remained constant over the years, essentially suggesting that the violence occurs at work and refers to a broad spectrum of behaviors (e.g., violent acts by patients, visitors, and/or coworkers) that result in a concern for personal safety. In fact, according to the National Institute for Prevention of Workplace Violence (n.d.), the second leading cause of death from women while at work is workplace homicides from assaults and other violent acts.

Settings for Workplace Violence: Emergency Department and Beyond

...frequent episodes of either physical violence and/or verbal abuse led to outcomes such as non-reporting due to fear of retaliation and fear of lack of support from employers. In 2009, the Emergency Nurses Association (ENA) published a groundbreaking study that outlines emergency nurses’ experiences and perceptions of violence in Emergency Departments (ED) across the United States (Gacki-Smith et al., 2009). Survey results from this descriptive study of experiences of 3,465 registered nurse ENA members noted a high prevalence of violence in this setting. Approximately 25% of the responders had experienced physical violence greater than 20 times in the previous three years. Nearly 20% reported encountering verbal abuse more than 200 times in that same time frame. Study responses indicated that frequent episodes of either physical violence and/or verbal abuse led to outcomes such as non-reporting due to fear of retaliation and fear of lack of support from employers. The researchers concluded that one factor important to mitigating workplace violence in the ED is commitment to ensuring a safer workplace by hospital administrators, ED managers, and hospital security.

Every 2 years, the ENA reviews and updates their position paper to reflect the latest evidence. Since the 2009 study (Gacki-Smith, et al.), the ENA conducts yearly surveillance of emergency nurses to keep a finger on the pulse of the front line and ensure that they are providing resources, and the most updated information, education, and guidance to their over 40,000 members. In the latest position paper in 2010, the ENA (2010) recognized workplace violence as a serious occupational risk that requires targeted responses from employers, law enforcement and the community. This position statement reported, “The health care industry leads all other sectors in the incidence of nonfatal workplace assaults, and the emergency department is a particularly vulnerable setting” (ENA, 2010, para 1). one factor important to mitigating workplace violence in the ED is commitment to ensuring a safer workplace by hospital administrators, ED managers, and hospital security.  ENA (2011) surveillance studies revealed that over 50% of the participating ED nurses experienced verbal or physical violence at work. Of all the nurses surveyed who reported physical assault, nearly half said they were pulled or grabbed, but the most common form of abuse was verbal, swearing and yelling.

What about violence that occurs in other areas in and outside the hospital? Workplace violence can strike anywhere. Some workers, however, are at increased risk. Among them are workers who exchange money with the public; deliver passengers, goods, or services; work alone or in small groups; work during late night or early morning hours; work in high-crime areas; or work in community settings and homes where they have extensive contact with the public. This group includes healthcare and social service workers (e.g., visiting nurses, psychiatric evaluators, probation officers); community workers such as gas and water utility employees, phone and cable TV installers, and letter carriers; retail workers; and taxi drivers (IMPACT, 2006-2007; U.S. DOL, 2002). Precipitating factors for the risk of violence included status as a behavioral health patient; patients who were under the influence of drugs or alcohol; crowding; and high patient volume and prolonged wait times. While the ED is often considered a microcosm of the community, and typically experiences issues like violence a bit earlier in the timeline than other inpatient units given its first point of contact status, workplace violence is an issue on many other units as well. Studies of emergency departments in the United States and other countries have clearly documented this specific nusing unit to be at risk (Camerino, Estryn-Behar, Conway, van der Heijden, & Hasselhorn, 2008; Catlette, 2005; Fujita et al., 2012; Gacki-Smith et al., 2010; Kowk et al., 2006). Precipitating factors for the risk of violence included status as a behavioral health patient; patients who were under the influence of drugs or alcohol; crowding; and high patient volume and prolonged wait times (Gacki-Smith et al., 2010).

While 4 out of 5 incidents of violence occurred in the ED, other areas of high stress, and thus incidence of violence, noted in the literature were the labor and delivery, maternal–child health units, and psychiatric settings. Data from the Pan American Health Organization (n.d.) noted that the incidence of domestic violence increases during pregnancy. Sensitive and emotionally charged issues related to pregnancy and childbirth may put nurses caring for patients in women’s health at risk. Another area with increased risk for exposure to violence is mental health settings (Chapman, 20009; Gerberich et al, 2004).

Financial Impacts of Workplace Violence

Workplace violence has both direct and indirect financial impacts for facilities. This section will briefly review a potential direct cost that may be incurred following acts of violence and also consider indirect consequences with financial ramifications, such as recruitment and retention.

Direct Cost

A major direct cost that results from acts of workplace violence is subsequent litigation... A major direct cost that results from acts of workplace violence is subsequent litigation from the party or parties involved. The cost to American businesses (all inclusive, not just health care businesses) from workplace violence has been estimated at $120 billion a year. The average jury award, in subsequent liability cases where the employer failed to take proactive, preventive measures under the 1996 OSHA guidelines, was $3.1 million per person per incident (IMPACT, 2006-2007; Whitehead, 2004).

Indirect Costs

While there are direct financial impacts of workplace violence, current overall cost estimates remain difficult to calculate due to the challenge of quantifying the burden of indirect costs related to workplace violence. ...current overall cost estimates remain difficult to calculate due to the challenge of quantifying the burden of indirect costs related to workplace violence.  For example, it is very important to also calculate lost work days that result from a violent event. The impact of lost wages on healthcare and nursing units may be seen indirectly in higher than average turnover; increased requests for medical leaves; unusually high time and attendance issues; and stress related illnesses.

The result of the trend toward increasing workplace violence, both externally from patients and visitors and internally with lateral violence  (also called bullying), is an unprecedented human capital challenge that is forcing leaders in organizations to rethink how they attract, retain, and continuously develop a pool of talented workers. Indeed, this is happening all over the globe. In a recent Accenture study (Accenture, 2004), executives in the United States, Europe, and Australia listed workforce-related issues, including safety, among their leading organizational priorities. Key issues cited by the respondents included: attracting and retaining skilled staff; reducing operational costs; improving employee retention and productivity; and improving workforce safety.

The cost of negative publicity is often hard to quantify, but can have a long term residual effect on the company. Of course, loss of life and suffering cannot only be measured by physical outcomes; there are many hidden costs involved as a result of the psychological ramifications of acts of workplace violence. For example, hidden costs may include an increase in medical claims for stress-related illnesses; psychological counseling for all employees after a violent incident; and time for managers and other administrators to address and be involved in investigations and time and attendance issues. One particularly challenging indirect cost may be loss of productivity following negative publicity after an incident. The cost of negative publicity is often hard to quantify, but can have a long term residual effect on the company (Sammer, 1998).

According to Nixon (2004) in, “The Financial Impact of Workplace Violence,” the cost of reacting after a serious incident has occurred is 100 times more costly than taking preventive actions. Even without precise cost information, it is clear that the overall impact and the resulting costs to industry of reacting to incidents after they occur can be staggering, versus the cost of prevention the violent acts in the first place. Focusing attention on safety and prevention must be the focus going forward! The Institute of Finance and Management (IOFM, 2011) reported that healthcare organizations spend nearly $5.50/ per employee on prevention of workplace violence. Current research continues to study a variety of ways to effectively prevent acts of violence in the workplace. While facilities need to work diligently to be proactive as they consider violence in the workplace, there are also actions that nurses can take to address workplace violence. The next section offers strategies that nurses have used and can use, either individually or as a group, to support awareness and appropriate actions to potentially mitigate the risk of violent acts at work.

Advocacy to Address Workplace Violence

State Laws

The ENA has been a leader in the effort to advocate for legislative consequences for those who commit an act of violence in the healthcare workplace. In part due to the work of this professional organization, more than half of the states in America have formalized a criminal penalty for such offenders. ...more than half of the states in America have formalized a criminal penalty for offenders.  This makes a strong statement that these acts will not be tolerated. The actual statutes and the degree of punishment for assaulting an emergency nurse vary from state-to-state. However, as of June 2012, 30 states had established penalties for assaults on nurses/healthcare personnel. Those states are:  Alabama, Arizona, Arkansas, Colorado, Delaware, Florida, Illinois, Indiana, Iowa, Kentucky, Massachusetts, Michigan, Minnesota, Missouri, Nebraska, Nevada, New Mexico, New Jersey, New York, North Carolina, North Dakota, Oklahoma, Pennsylvania, Rhode Island, South Carolina, Vermont, Virginia, Washington, West Virginia and Wisconsin. Other states are close. It should be noted that in the case of New York, the bill enacted in 2010 was actually the second bill regarding the assault of nurses/healthcare personal that was introduced and passed in that state. It was necessary to do this in order to close some loopholes that emerged from the initial law. An outline of state criminal laws protecting health professionals can be found on the ENA website in the Workplace Violence Management Toolkit (ENA, 2011).

Timeline for Bill Passage: The Ohio Story

It is often of great interest to those embarking on the journey of getting a bill through the complexities of the governmental bureaucracies to read about just how it can be done. Very similar to the bureaucracies of healthcare, it is time consuming and requires patience, persistence, and perseverance. Colleagues in Ohio, who very recently completed a successful effort, agreed to share their story with us (Chmielewski, N., December 2012, personal communication). See Table 1 for specific dates and legislative actions as the bill progressed to law.

The total time from its inception to passage was over three years, with five iterations of the bill before it was finally signed into law. Since the original inception in February 2010 of several bills to enhance the penalty against persons who commit violence against healthcare workers, the Ohio bill was presented to the House Criminal Justice Committee three times over the course of a year. During the spring of 2011, the bills had a series of three sessions where the bill was passed as a substitute bill and finally was passed with multiple changes. Following that, it was introduced to the Senate for hearings and was assigned to Senate Criminal Justice Committee. The first hearing was cancelled. Following a structural redesign, the Senate President merged the civil justice and criminal justice committees into a single judiciary committee, and reassigned the bill to the newly formed committee. After a period of six months, and at the 6^th hearing, a substitute version passed out of the Senate Judiciary Committee. The billed was passed on the 3^rd Consideration (Senate Floor Vote). It was informally passed, a technical amendment offered, and then formally passed on same day. There was a House concurrence vote to Senate amendments. Finally, the act was sent to Ohio Governor John Kasich for signature or veto. The act was signed by the Ohio Governor and received by the Ohio Secretary of State. The act is effective March 3, 2013. The total time from its inception to passage was over three years, with five iterations of the bill before it was finally signed into law. The recent success of this important piece of legislation in Ohio, and the story behind it, illustrates the need for advocacy and perseverance.

Policies and Procedures

Many organizations have zero tolerance policies in place... but what is most important is how the policies are implemented and enforced. In addition to legislative advocacy to support penalties for those committing acts of violence against healthcare workers, understanding the issue, providing education to employees, and supporting anyone involved in an incident of workplace violence are some key essentials to dealing with the problem. Many organizations have zero tolerance policies in place. These policies all look very good in print, but what is most important is how the policies are implemented and enforced. It is imperative that the policy is utilized.

When it comes to assessing risk, statistics can sometimes be deceiving. Executives and risk managers may examine regional and national data, compared with their own internal statistics, and deem the risk too low to merit attention. However, what is often underestimated is not the cost of action (proactive steps to avoid violence), but rather the cost of inaction: the widespread financial consequences when an incident occurs as described above (IMPACT 2006-2007). It is important for nurses first to be aware of the scope of the financial burden of workplace violence. Second, they need to be able and willing to articulate this concern at the decision-making tables as they work with employers to assess and mitigate risks and develop appropriate institutional level policy.

Education

Ensuring that healthcare providers have the appropriate education and training to recognize, diffuse, and deescalate violent behaviors is essential. There are many different courses available for individual or group enrollment. The key is to align the course content with the culture and needs of your individual organization. Consider training in a multidisciplinary forum.  The key is to align the course content with the culture and needs of your individual organization. Consider training in a multidisciplinary forum. In the authors’ facility, we practice and train for clinical scenarios such as trauma and code responses biannually and at monthly staff education session. Everyone needs to know what happens when a patient turns violent and we may need assistance from our security and safety partners. Asking the following questions can guide these sessions: Do we speak the same language (i.e., use common terminology, which may be facility-specific) as we initiate and continue the response? Do we know the wealth of knowledge that each team member brings to the table? Do we understand each others’ unique roles and responsibilities? Also important in an area where there can be frequent employee turnover: Do we even know each other’s names?

Practicing BEFORE issues occur helps ensure the safety of all involved and the best outcome for the patient(s). All members of the team need to know their roles and responsibilities as well as what to expect from other team members. Practicing BEFORE issues occur helps ensure the safety of all involved and the best outcome for the patient(s). There are multiple free resources available (see Table 2) to allow each organization to provide individualized and unique educational programs for their employees. The content of each program should be specifically designed to address patient populations; patient care needs; staff awareness and readiness to learn; and organizational resources.

Conclusions

Workplace violence is not a part of the job. While we understand that there are inherent risks with patients experiencing behavioral health emergencies, dementia, and other organic complexities, or perhaps visitors who are under duress, we cannot become complacent. There is not one simple solution. Advocacy for state legislation; creating and enforcing facility policies; and providing education with practice are important strategies. Additional strategies that may have to be considered in some areas are metal detectors and dedicated security personnel. The human resource department should be involved to ensure that policies and procedures are in effect and implemented correctly. Table 2 provides a list of resources that nurses can access that may be helpful to advocate for action related to mitigating workplace violence. However, what is most important is an understanding of the impact that experiencing an act of workplace violence has on the healthcare provider. We must provide appropriate real time support and ongoing resources to ensure that the person on the receiving end of a violent act feels valued, respected, and safe.

Acknowledgement. Many thanks from the authors to Nicholas Chmielewski, MSN, RN, CEN, NE- BC, Government Affairs Liaison for the Ohio Emergency Nurses Association, and his team, for sharing their story.

Authors

AnnMarie Papa, DNP, RN, CEN, NE-BC, FAEN
E-mail: AnnMarie.Papa@uphs.upenn.edu

AnnMarie Papa is an energetic and engaging leader that has mentored and inspiredmany. She has presented on topicsrelated to emergency nursing regionally, nationally and internationally. Holding a BSN and MSN from VillanovaUniversity in Villanova, PA and a DNP from Waynesburg University in Waynesburg, PA, Papa is also a Fellow in theAcademy of Emergency Nursing.

Papa is a thought leader and sought after speaker on leadership, mentoring, and manyother topics. She has been recognizedfor her exemplary leadership with local, state, and national awards. Most recently she was recognized as one ofHealth Leaders Media Top 20. She has served in a number of state, local andnational leadership positions. In 2011she served as the National ENA President and she is currently Director of the TransitionUnit and the ED at the Hospital of University of Pennsylvania and PennPresbyterian Medical Center.

Jeanne Venella,DNP, MS, RN, CEN, CPEN
E-mail: Jeanne.Venella@uphs.upenn.edu

Dr. Jeanne Venella is an accomplished emergency nursing expert and has been widely recognized as one of the nation's foremost experts in leadership, change management, customer service, and patient throughput in healthcare. She has extensive experience as an innovative leader in health care management and a proven working knowledge of day-to-day operations. She influences and motivates her clients to create a culture of quality and safe patient care, coupled with excellent outcomes, and exceptional service. She provides a detailed framework and practical strategies that create and inspire positive change. She has spent her career transforming emergency nursing care, assessing operations, prioritizing needs, identifying opportunities, and improving processes with sustained results.

As a Certified Emergency Nurse and Certified Pediatric Emergency Nurse, Jeanne worked at the nation's leading tertiary pediatric hospital for over 25 years. She has been recognized as a clinical expert in the specific and unique needs of children in disaster and bio-terrorism.

Jeanne has lectured at numerous national and state nursing conferences on a variety of emergency nursing and professional development topics. In 2009, she was awarded the College Medallion Award, the highest alumni award from Villanova University's School of Nursing. Jeanne received her Bachelors of Science in Nursing from Villanova University in Villanova, PA and went on to obtain a Master’s of Science in Organizational Leadership from Cabrini College in Radnor, PA.  She just recently was conferred a Doctor in Nursing Practice from Waynesburg University in Waynesburg, PA.

Accenture. (2004) The High-Performance Workforce Study2004. Retrieved from https://www.cpp.com/pr/accenture.pdf.

Anderson C. Workplace violence: are some nurses more vulnerable? Issues in Mental Health Nursing, 23(4), 351-366.

© 2013 OJIN: The Online Journal of Issues in Nursing
Article published January 31, 2013