No unit is immune to workplace violence
The ED and other units can identify strategies to keep patients and staff safe
Heather Stringer
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Lisa Wolf, PhD, RN, CEN, was working in the emergency department at
Cooley Dickinson Hospital in Northampton, Mass.,
when she experienced a painful reminder that workplace violence is a reality for nurses. She was caring for a psychiatric patient in his 80s, and as she attempted to move him in his bed, the patient kicked her in the face. The blow to her temple left her momentarily confused and in considerable pain. If the patient had been wearing shoes, Wolf suspects she would have been knocked unconscious.
“People are often stunned when they hear about the frequency of workplace violence in nursing,” said Wolf, director of the Institute for Emergency Nursing Research at the
Emergency Nurses Association
. “Other patients and staff are often not aware that it’s happening because these incidents occur behind curtains or closed doors.”
According to a survey of more than 7,000 emergency nurses nationwide, more than 54% of participants reported experiences of physical violence or verbal abuse within the past seven days. The leading forms of physical violence were being grabbed/pulled, hit, spit on and pushed/shoved/thrown, while the most common types of verbal abuse were being yelled at, sworn at, called names or threated with legal action. The full study was published in 2011 by the ENA.
For Wolf, one of the disturbing discoveries was that 33% of nurses in the study said they considered leaving the profession due to the violence. “This is a huge problem because this could be a significant loss of expertise and experience, which would have implications for patient care,” Wolf said.
Findings from a different study of 5,000 nurses at Inova Health System in Virginia suggest that violence is also prevalent in other hospital units. Forty-four percent of nurses in inpatient units reported incidents of workplace violence within a year — higher than the EDs or psychiatric units at Inova, according to the 2014 study in the Journal of Emergency Nursing. Also, male nurses experienced fewer incidents of violence, but they were more likely to formally report these incidents.
“People are often stunned when they hear about the frequency of workplace violence in nursing.”
— Lisa Wolf, PhD, RN, CEN
Interventions that reduce risk
At Inova, the violence research study prompted hospital-wide changes to create a safer environment, said Tammy Fitch, RN, CCRN, a nursing supervisor at Inova Loudoun Hospital in Leesburg, Va. In the past, only psychiatric unit staff were required to complete a yearly crisis prevention and intervention class, and now the EDs are doing the same.

In the training, Fitch learned how to watch for signs that a patient may be escalating emotionally, such as posturing behavior like pacing or verbal cues like rapid speech or a higher tone of voice. She used these skills recently when a patient in his 20s started pacing in front of the door in his room. Fitch started talking to the patient’s mother to ease the tension, and she was careful not to turn her back on the patient as she moved herself closer to the door to unblock her exit pathway.
Wolf also encourages nurses to download the ENA’s Workplace Violence Toolkit, which allows departments to customize a violence prevention plan after assessing which situations most commonly lead to violence. “There is no one-size-fits-all intervention,” Wolf said. “Nurses should consider what types of patients are higher risk in their unit, where it is happening, such as triage or in the hallway, and if there are certain times of the day or night it is more likely. Then they can direct the intervention to address those issues.”
American Psychiatric Nurses Association
also has developed online toolkits to help nurses enhance skills that decrease the chances of workplace violence, such as patient engagement techniques. Establishing a human connection with the patient is perhaps one of the most important skills nurses can acquire to keep themselves safe, said Diane Allen, MN, RN-BC, NEA-BC, chair of the Council of Safe Environments for APNA.
“Sometimes this may seem counterintuitive when we are feeling afraid of a patient, but it’s critical to make that connection and explain to a patient that I’m on his or her side,” said Allen, who is acting director of nursing at New Hampshire Hospital in Concord, an acute, inpatient psychiatric hospital.

The majority of the patients at her hospital have been admitted involuntarily because they have been deemed dangerous due to mental illness, and many of them do not recognize that they have an illness. She’s treated patients who tell her they need to leave, and rather than becoming controlling, Allen offers to help them understand why they were admitted and what they can do to get discharged.
“When I focus my attention on trying to understand their biggest concerns, whether it be getting a glass of water or making a phone call, I have built an alliance that can carry over as I continue working with the patient,” she said.
Although organizations like the APNA are promoting practices that increase safety for nurses, research suggests that nurses need even more support. According to a study published in Research in Nursing & Health, assault rates in psychiatric units have not changed significantly over time. In the study, researchers collected data from 345 hospitals nationwide between 2007 and 2013, and they found that nursing staff members were the most severely injured victims in assaults in 65% of cases during those six years. When nurses are assaulted, it’s important for organizations to provide support, such as employee assistance programs and assaulted staff action programs, Allen said.
“Nurses shouldn’t expect violence to be a part of providing care,” she said. “As demand for services continues to increase with the aging baby boomers and more nurses retiring, it’s more important than ever for nurses to take steps to protect themselves and their units.”

How to protect yourself
Communicate frequently and thoroughly with colleagues to identify potentially violent patients early
Don’t let a patient get between you and the only exit
If you are feeling threatened, turn your body sideways with one foot in front of the other. This helps you to keep balanced and presents a smaller target to the aggressor
Don’t point your finger at people. Fold your arms or put your hands on your hips when talking
If a patient is escalating, call for help early from colleagues or security
Do not wear dangling earrings or necklaces
Do not wear a stethoscope around your neck
When possible, do not block a patient who wants to leave
Sources: Lisa Wolf, PhD, RN, CEN, and Diane Allen, MN, RN-BC, NEA-BC
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Heather Stringer is a freelance writer.
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