Nursing Profession and Workplace Violence

Afza.Malik GDA

Workplace Violence and Nursing Profession

Nursing Profession and Workplace Violence

Workplace Violence,Four Categories of Work place Violation,Homicide as Major Cause of Death,Fatal and Non Fatal Assault,Reporting of Work Place Violation,Incidence Reporting of Assault,Factors Associated With Assault,Assault in Psychiatric Setting,How Prevent Violation,Outcomes of Interventions.

Workplace Violence

    Workplace violence is defined as “violent acts (including physical assaults and threats of assaults) directed towards persons at work or on duty” (National Institute of Occupational Safety and Health [NIOSH], 2002). Most workplace violence falls into one of four categories.

Four Categories of Work place Violation

    Type I (Criminal Intent): Results while a criminal activity (eg, robbery) is being committed and the perpetrator has no legitimate relationship to the workplace.

    Type II (Customer/Client): The perpetrator is a customer or client at the workplace (eg, health care patient) and becomes violent while being served by the worker.

    Type III (Worker-on-Worker): Employees or past employees of the workplace are the perpetrators in this case,

    Type IV (Personal Relationship): The perpetrator in this case usually has a personal relationship with an employee (eg, domestic violence in the workplace).

Homicide as Major Cause of Death 

    Homicide has remained among the top three causes of death in the workplace since 1990. According to the Bureau of Labor Statistics (BLS), workplace violence is the third leading cause of occupational injury death among all workers and the leading cause among women. 

    Workplace homicides have declined from a high of 1,080 in 1994 to 609 in 2002; on average 846 workers per year have died as a result of homicide since 1992. Notably, 80% of workplace homicides involve the use of a firearm (NIOSH, 1996).

Fatal and Non Fatal Assault 

    Nonfatal assaults are much more common than fatal assaults. Although both share many of the same risk factors (eg, contact with the public, working with volatile persons, working in small numbers, and working in community based settings) health care rather than retail workers represent the majority of victims of nonfatal workplace violence. 

    According to the Department of Justice's National Crime Victimization Survey (NCVS), 1.9 million incidents of workplace violence occurred in the workplace each year from 1992-1996 ( Warchol , 1998). 

    Twelve percent of all victims reported physical injuries; 6% of the workplace crimes resulted in injury that required medical treatment, and only 44% of all incidents were reported to the police.

Reporting of Work Place Violation 

    Workplace violence is a documented occupational hazard in the health care and service sectors (NIOSH, 2002; Lipscomb & Love, 1992; Warchol , 1998). The health care sector leads all other industries in nonfatal work place assaults. 

    In 2000, 48% of all nonfatal injuries resulting in days away from work from violent acts and assaults occurred in the health and social service sector (BLS, 20011. The incidence rate for violent acts and assaults resulting in days away from work was 9.3 per 10,000 full-time workers for health services workers compared to an overall private sector injury rate of 2 per 10,000 full-time workers (BLS).

    Among victimizations reported in the NCVS, mental health professionals had an incidence rate of 79.5 per 1,000 workers compared with an overall rate of 14.8 per 1,000 workers.Nurses had an incidence rate of 24.8 per 1,000 workers, the highest rate in the “medical” category (War chol ) .

    Violence in mental health has an extensive history, with the first documented case of a patient fatally assaulting a psychiatrist in 1849 (Bernstein, 1981).Until the 1990s, most studies that examined the risk of violence to psychiatrists and other therapists focused on the victim's role, the assaultive patient's characteristics, and contextual factors surrounding the assault . 

    Only recently have environmental risk factors been a focus of research and nurses and aids the subjects of study.

Incidence Reporting of Assault

    Bensley and colleagues (1997) compared the number of workers compensation claims from a Washington State psychiatric hospital, formal incident reports, and the number of incidents of assault reported on a survey measuring attitudes and experiences related to assaults. 

    She found that 73% of staff surveyed reported at least a minor injury related to a patient assault in the past year. Only 43% of those reporting moderate, severe, or disabling injuries related to assault filed a workers compensation claim. 

    The survey found an assault incidence rate of 437 per 100 employees per year, a rate that underestimated incident reports of assaults by a factor of more than five ( Bensley et al.).

Factors Associated With Assault

    Environmental and organizational factors have been associated with patient assaults, including understaffing (especially during times of increased activity such as meal times), workplace security, time of day, unrestricted access to movement and transporting patients (NIOSH, 2002). 

    SS Lee, Gerberich , Waller, Anderson, and McGovern (1999) found that among 105 nurses who had filed a workers compensation claim for work related assault injuries, the presence of security personnel reduced the rate of assault while the perception that administrators considered assault to be part of the job, having received assault prevention training, a high patient/personnel ratio, working primarily with mental health patients, and working with patients who had a long hospital stay increased the risk of assault.

    The one characteristic patient that has been singled out as a strong risk factor for violence is a history of violent behavior. A number of studies have documented that a small number of patients are responsible for the majority of assaults ( Hillbrand , Foster, & Spitz, 1996). 

    Drummond, Sparr , and Gordon (1989) examined an intervention designed to identify patients with a history of violence and found that flagging charts of patients with histories of assaultive or disruptive behavior reduced assaults against staff by 91%.

Assault in Psychiatric Setting 

    Many psychiatric settings now require that all patient care providers receive annual training in the management of aggressive patients. However, few studies have examined the effectiveness of such training. 

    Those that have generally found improvement in nurses' knowledge, confidence, and safety after taking an aggressive behavior management program ( Hurlebaus & Link, 1997), Carmel and Hunter (1990) examined the relationship between participation in training and aggressive behavior by inpatients on 27 inpatient wards in a California State hospital and found that wards with higher staff attendance at the training experienced lower rates of injury. 

    Lehman et al. (1983) found significantly higher knowledge and confidence in trained staff.

How Prevent Violation 

    Runyan, Zakocs , and Zwerling (2000) reviewed 137 papers mentioning violence prevention intervention and found that only ten of the papers reflected databased intervention. 

    All interventions took place in health care, five studies evaluated violence prevention training interventions (including Lehmann and colleagues, and Carmel & Hunter), three examined post incident psychological debriefing programs, and two evaluated administrative controls to prevent violence. All were quasi experimental, without a formal control group and with equivocal findings.

    The health care workplace must be made safe for all health care workers through the use of currently available engineering and administrative controls, such as security alarm. systems, and adequate staffing and training. 

    The Occupational Safety and Health Administration published “Guidelines for Preventing Workplace Violence for Healthcare and Social Service Workers.” 

    These guidelines describe the key elements of any proactive health and safety program including: management commitment and employee involvement, a written violence prevention program, a worksite analysis, hazard prevention and control, medical management and post incident response, training and education, and record keeping and evaluation of the program. 

    These authors are currently evaluating the effectiveness of these guidelines in preventing violence within the mental health and social service work settings. Preliminary findings from the inpatient mental health workplace indicate that a comprehensive violence prevention program is associated with a reduction in risk factors for violence and workplace threats and assaults (Lipscomb, in preparation).

Outcomes of Interventions

    Research evaluating intervention directly at the primary, secondary, and tertiary prevention of violence across health care settings is critically needed to reduce workplace violence and ultimately improve patient care. A secure and healthy work environment is essential to a positive environment of care.

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