Violence and Abuse in Health Care Settings: An Increasing Challenge

This commentary provides a partial review of the consequences of violence bullying and incivility for nursing staff. These factors are widespread and increasing. Each of these factors has been shown to have negative effects on nurse job satisfaction, job performance, quit intentions and psychological and physical health. Most victims are uncertain of the best ways to respond to these experiences. Sources of each include patients, families of patients, physicians, supervisors and co-workers. Interventions that have proven to be successful in reducing workplace violence, bullying and incivility in nursing settings are described. Common factors include developing policies and procedures to recognize and indicate when one is experiencing these, informing those at senior levels, investigating the incidents and providing follow-up care and support. Staff training to recognize potential threats and ways to best respond to them is vital but not always offered to staff. I have undertaken research on the work experiences of nursing staff over the past 25 years. My first project, with the Ontario Nurse’s Association, studied the effects of hospital restructuring and budget constraints on the quality of work life, satisfaction and performance of nursing staff. Other research projects in the US and Turkey examined workplace factors such as hospital culture associated with work engagement, satisfaction and psychological well-being of nursing staff. This commentary takes a different tack. I am now editing a book for Gower titled “Violence and abuse in and around organizations.” In identifying potential chapters I came across studies of workplace incivility and violence in health care settings suggesting these are increasing documents increasing levels of violence towards nurses from patients and visitors in all countries. As I am writing this, nursing staff worldwide are experiencing violence, abuse and incivility. Warplanes from Russia, the US and Syria are dropping bombs on hospitals in Aleppo, accidentally or deliberately, killing nurses, patients and families of patients. A sample of this material forms the basis of this commentary. It will consider violence, bullying and incivility in health care settings focusing on the experiences of nursing staff. Citation: Burke RJ (2016) Violence and Abuse in Health Care Settings: An Increasing Challenge. Primary Health Care 6: 244. doi:10.4172/21671079.1000244

*In Toronto, the Canadian Centre for addiction and Mental Health (CAMH) were found guilty in the beating of a nurse by a patient in 2014. CAMH had not developed nor implemented measures to protect the safety of its employees. The nurse suffered PTSD and depression and has not returned to work. The patient had attacked a nurse in another facility earlier.
*A pregnant emergency nurse was beaten by a mentally ill patient while attending to another patient. She was knocked unconscious and hospitalized.

Violence
Workplace violence refers to any act in a workplace where an individual is threatened. Abused, intimidated or assaulted.
Yang et al. collected data in a longitudinal study from 176 nurses working in two US hospitals [2]. They examined whether exposure to violence was associated with somatic and musculoskeletal disorders and whether the hospital's violence prevention climate as perceived by nurses predicted nurse violence exposure. Exposure to physical violence included being bitten, grabbed, hit with an object, kicked, punched, slapped, spat upon and assaulted with a weapon. Hospital violence prevention climate included encouraging nurses to report incidents of physical violence, establishing and communicating violence policies and procedures and putting violence prevention before pressures to get their jobs done. Violence exposure predicted somatic symptoms as well as upper body/lower extremity and lower back pain over the six month period. In addition, perceived violence prevention climate predicted nurse's odds of being exposed to physical violence over the six months.
Sofield and Salmond, in a sample of 461 US nurses reported that 91% had experienced verbal abuse in the past month, most indicating 1-5 abuse incidenis [3]. Verbal abuse most frequently came from physicians, followed in turn by patient's families, patients, other nurses one's immediate supervisor and subordinates. Nurses reporting more verbal abuse were also more likely to intend to quit. Nurses indicated low levels of ability in dealing with experienced verbal abuse. Most common responses to abuse were anger, feeling powerless, feeling harassed and concerns that their issues here were not being addressed.
Spector et al. undertook a quantitative review of 136 articles using data from 151,347 nurses in 136 different samples, to examine effects of nurse exposure to physical and non-physical violence, bullying and sexual harassment [4]. Exposure rates for physical violence were 36%, non-physical violence (47%), bullying (40%) and sexual harassment (25%) with 33 being physically injured during an assault. Experience rates were compared in four world regions: Anglo, Asia, Europe and Middle East, with response rate differences observed. Physical violence and sexual harassment were highest in the Anglo region, with nonphysical violence and bullying highest in the Middle East. Patients

The Importance of Staff Training
Beech and Leather illustrate the importance of "management of aggression" training in reducing levels of violence in nursing settings [10]. Unfortunately such training is still the exception not the norm. Training programs should increase understanding of aggression and violence and their potential sources, ways of assessing levels of risk and useful precautions, how to interact with an aggressive individual and post-incident reporting of investigations and counseling with necessary follow-up actions. They stress also the importance of assessing the effectiveness of such training to increase its relevance and value.

Reducing Workplace Incivility
Interestingly, the best examples of successfully reducing workplace incivility involve nursing settings. We will describe one such intervention but interested readers can find other detailed descriptions in Leiter [11]. Many of these use the acronym CREW (Civility, Respect and Engagement in the Workplace). Laschinger et al. in a longitudinal study of nurses (n=755 at time 1 and n=573 at time 2) working in 41 nursing units in five hospitals in two Canadian provinces, created experimental groups (n=5) and control groups (n=33) [12]. The experimental units were given the CREW intervention. Significant improvements in the experimental units were observed for supervisor civility; trust in management and work engagement. The intervention involved weekly staff meetings for some periods of time, team building exercises, ways of recognizing the positive contributions of peers, discussion of the CREW program at monthly meetings and identifying issues that emerged or remained and developing solutions.

Conclusion
Violence and abuse of nurses is widespread and has important consequences in terms of more negative work attitudes, diminished health and safety, reduced job performance and greater intentions to quit the profession. Violence among nursing staff has also been studied and reported in Emergency departments in Ankara Turkey, Iran, and Australia. Nurses in some units report higher levels of violence (e.g. emergency units, psychiatric units). The best predictor of violent behavior by an individual is a past incident of violent behavior.
accounted for most violence in Anglo and European regions with family of patients in the Middle East.

Domestic Violence
Domestic violence should also be seen as a workplace issue requiring an organizational response. Domestic violence has organizational costs in terms of lost productivity, more absenteeism and increased health care costs. Workplaces then need to be aware that domestic violence affects their employees. Workplaces can take steps to protect potential victims, training employees on how to respond to an abuser at work increasing security against unauthorized visitors, creating and disseminating information on domestic abuse, allowing victims time off to make court appearances, referring employees to internal employee assistance programs or external domestic abuse programs and helping their own employees who abuse.

Bullying
Bullying involves a persistent form of abuse involving negative unpleasant workplace interactions. Bullying can take place laterally between colleagues at equal rank as well as horizontally from those of higher and lower rank. Bullying is complex in that it involves individual (victim and aggressor), social (interpersonal skills) and organizational (culture and norms).
Vogelpohl et al. carried out a study of bullying among newly graduated nurses in Ohio. Three types of bullying were considered: person-related (having opinions ignored, closely monitored), workrelated (being humiliated and ridiculed, being ignored or treated with hostility) and physically intimidating bullying (being shouted at, intimidating behaviors) [5]. Nursing peers, physicians and patient families were the main sources of bulling. About 70% of new nursing respondents considered leaving nursing. Johnson reviewed published literature on bulling among nurses and found that bullying reduced nurse's physical and psychological well-being and their job performance [6].

Workplace Incivility
Workplace incivility refers to employee's mistreatment or lack of regard for one another. Incivility is a common occurrence in nursing and has negative consequences for satisfaction and performance. Stanley et al. in a study of 663 nursing staff in the US [7]. Reported that 46% saw incivility as a "very serious" or "somewhat serious" problem, with 65% reporting observing incivility among co-workers. Laschinger et al. in a study of newly graduated nurses reported that the experience of incivility was associated with higher levels of nurse burnout [8].

Reducing Workplace Violence
Wassell reviewed writing over a 17 year period on the effectiveness of workplace interventions to reduce violence with over half addressing the health care sector. He identifies three types of interventions to reduce workplace violence [9].
These were: Environmental -lighting entrances and exits, increasing security, screening visitors; Organizational and Administrativecreating programs, policies and practice to increase safety, more security in some units (emergency, Psychiatric), not working alone in a unit at night, Behavioral and Interpersonal -training staff to anticipate, identify and respond to potential and actual violence of conflict, how to deal with patient and family violence. In addition, in many countries various governmental agencies have developed guidelines for reducing violence among health care workers.