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What Will It Take to End Violence Against Nurses?

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More nurses are opening up about on-the-job violence.

Some groups are encouraging the candid conversation about workplace violence, hoping to create awareness and come up with solutions, while avoiding backlash. An emergency department nurse at Providence Portland Medical Center, James (J.R.) McLain, RN, said patients threaten, verbally abuse, spit at or grab him just about every shift. McLain shared his story earlier this year with the Willamette Week newspaper. The violence has escalated in recent years, in part because of patients coming into the ED with methamphetamine-induced psychosis, according to the article. McLain is not alone. Seven in 10 U.S. emergency nurses report having been hit or kicked on the job, according to the No Silence on ED Violence homepage. The American College of Emergency Physicians and the Emergency Nurses Association launched No Silence on ED Violence in 2019 to support and empower ED staff. But the problem is by no means limited to the ED. One in four nurses are assaulted; up to 80% of workplace violence incidents affecting nurses go unreported; and 13% of missed workdays can be attributed to workplace violence, according to ANA's End Nurse Abuse campaign. Researchers studying all types of nurses from a U.S. urban community hospital found in one year 76% of nurses experienced violence, including verbal and physical abuse from patients and visitors. Emergency nurses at the hospital experienced an even greater number of incidents, according to the study, published May 2014 in the Journal of Emergency Nursing.

It doesn't come with the territory

ENA President Mike Hastings, MSN, RN, CEN, said ED nurses encounter foul language, name calling, spitting and much more. [caption id="attachment_76513" align="alignleft" width="200"]violence Mike Hastings, RN[/caption] Unfortunately, the world of nursing has kind of a "This is your job, take it and roll with it" mentality, Hastings said.

"I think that over the last couple of years we've started talking about it and said, "You know what, it is not your job. It is not your job to be spit at, kicked at. It's unacceptable,'" Hastings said. "We don't accept that behavior anywhere else in our society. So why should we accept it in our hospitals where the healthcare workers are there to care for you."

Stressors like the COVID-19 pandemic can fuel violence against nurses. That's likely because patients are anxious and have to wait longer to be seen in overcrowded EDs, according to Hastings. Sandra Risoldi, DNP, RN, CLNC, started the nonprofit Nurses Against Violence Unite to give nurses a voice and support, create awareness, empower nurses and eliminate workplace violence. That includes violence from patients and coworkers. The Nurses Against Violence Unite Facebook page had nearly 8,600 members in April. [caption id="attachment_76514" align="alignright" width="214"]violence Sandra Risoldi, RN[/caption] Risoldi attributes increased violence to several factors, including that nurses aren't able to build relationships with patients the way they used to; patients' healthcare needs are more complex; and many nurses on the floor (outside the ED) are not trained in opioid and alcohol withdrawal.

"These nurses are not prepared," Risoldi said. "These patients are irritable or out of control and the nurse comes in and could get the full brunt of this anger."

Nurses often feel like they have nowhere to go and no one to talk to when it comes to workplace violence. Nurses Against Violence Unite provides a safe place for nurses to talk, anonymously if they so choose, according to Risoldi.

Solutions start at work

Hastings, a clinical manager for Swedish Edmonds Emergency Department in Edmonds, Wash., said nurses need help from hospital administrations and communities in which they work to solve the problem. For administrators, tackling workplace violence starts with creating a culture in the work environment in which it is not accepted, according to Hastings.

"The frontline staff need to know that administration is there to support them," Hastings said. "Encourage them to report the problem and have a way to track incidents in your facilities. Then use that data to figure out mitigation strategies that will work."

ENA's research shows incidents of workplace violence are underreported because nurses think it is part of the job, or they don't feel they have their organization's support, local law enforcement or the legal system, Hastings said. Hastings encourages staff to report violence when it happens. "Unless you report it, we don't know it happens," Hastings said. Hastings said he follows up with nurses who report violence and supports them if they decide to press charges. Risoldi said it's not only that nurses should be able to report violence, but they should have the option to do so anonymously. To protect themselves on the job, nurses should have situational awareness at all times.

"Realize that every situation is different," Hastings said. "The way they handle a situation one time is not necessarily going to work in the next situation."

Nurses should keep themselves at safe distances from patients to prevent physical contact whenever possible, and never go alone to treat a patient whose mental state is already escalated, Hastings said. Hospital security's presence can de-escalate some situations. But often security can't respond quickly enough to prevent violence, according to Risoldi. Nurses should consider getting involved with their employers' workplace violence committees. Risoldi recommends that nurses build relationships with their peers and in groups like Nurses Against Violence Unite. "It's important for the nurse to be able to release," Risoldi said. Our profession is suffering from alarming rates of burnout and post-traumatic stress. Nurses are also resorting to taking their own lives because of the loneliness. They feel like they're alone and nobody understands what they're going through. So they come to us and it's a huge release." No Silence on ED Violence aims to collect numbers on incidents to better define the problem and encourage politicians to pay attention to solving it, according to Hastings. The ENA strongly supports a bill that the U.S. House of Representatives voted to approve in November 2019, called The Workplace Violence Prevention for Health Care and Social Services Act of 2019. H.R. 1309 ensures healthcare and social service employers, including hospitals, take specific steps to prevent workplace violence and ensure the safety of patients and workers, according to the ENA. The bill has passed in the House but has not yet passed the Senate. Nurses need to make sure legislation to protect them includes all nurses. According to Risoldi the way some legislation is written, it's a felony to assault an emergency room provider or mental health therapist, but not a nurse on the floor. "Every state is different," Risoldi said.

More resources for nurses

For more information on anti-violence initiatives and more, visit: The Silent No More Foundation (founded by a critical care nurse) CDC course: Workplace Violence Prevention for Nurses For more on laws that protect nurses by state, go to ANA's workplace violence page.

Take these courses on workplace violence:

CE130-60: Preventing Violence in the Healthcare Setting (1 contact hr) Violence in healthcare reflects the chaos of a broader work environment. The National Institute for Occupational Safety and Health defines workplace violence as "violent acts (including physical assaults and threats of assaults) directed toward persons at work or on duty." Experts not only agree on the extent of violence in the healthcare setting, but they also concur on its best treatment -- education and prevention. Nurses heighten their awareness and expertise in dealing with violence in their professional settings by learning to identify risk factors and warning signs and by applying interventions that could shield their patients and themselves from harm. WEB296: Nurse Bullying: Stereotype or Reality? What Can We Do About It? (1 contact hr) October is Bullying Prevention Month. Have you ever felt bullied in the workplace? How has the "nurses eat their young" idiom survived through nursing history? In the past few years, interesting research has emerged ranging from workplace aggression to incivility to nurse bullying. Knowledge is power. Become equipped to professionally challenge bullying in the workplace and empowered to demonstrate good examples of nursing leadership in our profession!