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Problem Based Research Paper: Violence in the Health Care Setting

Nursing 340: Nursing Research

Delaware Technical Community College

October 6, 2019

Veronica Payne
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For those working in the health care industry, the somber reality is that at some point in their

career they will face verbal and or physical abuse from patients and or patient’s family members.

Violence against health care workers, especially registered nurses, has made national headlines in recent

years. In 2014, chilling video surveillance from a Minneapolis hospital showed a patient attacking nurses

with a metal bar. In April of 2019, a nurse in Baton Rouge attempted to help a co-worker who was being

attacked by a patient. The nurse later died from complications that were a direct result of injuries

sustained during the attack. Violence directed towards nurses is, disturbingly, an everyday occurrence.

Just as disturbing, these verbal and physical threats are often accepted as the norm, not reported or

brushed off by employers.

“While data varies, different sources point to the conclusion that health care workers, and

particularly registered nurses who provide the bulk of hands-on-care to patients and their families,

suffer the highest rate of workplace violence among all occupations… the U.S. Occupational

Safety and Health Administration (OSHA) states that over a 12-month period in 2014, 21 percent

of RNs and nursing students report being physically assaulted, and more than 50 percent are

verbally abused” (Hwang, 2016).

Being verbally abused and or injured from a violent patient or patient’s family member should not be

considered “part of the job” for registered nurses. Prevention efforts, protections and penalties must be

established nationally to allow registered nurses and other health care professionals to effectively perform

their job duties.

Statement of the Problem

Currently, “federal standards do not require workplace violence protections though some states

have sought legislative solutions including mandatory establishment of a comprehensive prevention

program for health care employers, as well as increased penalties for those convicted of assaults of a

nurse and/or other health care personnel” (American Nurses Association, 2016). Currently, only nine
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states require by law public employers to have established workplace violence programs, while thirty-six

states have laws designating penalties for assaults that include nurses. However, nine of those thirty-six

states are site specific, meaning the law only applies to emergency department or mental health/psych

personnel. There is no law in the State of Delaware requiring public employers to run workplace violence

programs. It wasn’t until September of 2016, when Delaware Governor Jack Markell signed House Bill

214 raising the penalties for assaults on nurses, previously the law had only covered first responders.

In November of 2018, House Democrats introduced the Workplace Violence Prevention for

Health Care and Social Service Workers Act. Highlights of this law include: medical facilities being

required to establish protocols and safety plans for violent patients, required security improvement,

required follow up investigation by employers after every violent incident, protection of employees from

punishment or retaliation after reporting violent events, and staff training on how to respond to violent

patients. This act advanced out of the second stage of the legislative process in June of this year.

While future laws are tied up in the legislative process, health care facilities should utilize

research to best design violence prevention plans. As in all sectors of the health care industry, it is more

effective to be proactive rather than reactive. “Making health care settings safe for registered nurses and

all other health care professionals means that these workplaces are, in turn, safe for providing high-

quality, therapeutic care” (Hwang, 2016).

Literature Review

Identifying risk factors for violent situations is discussed in the article Unnecessary Risk, by

Lucia Hwang. “With workplace violence, solutions to prevent violence are of course always preferable to

dealing with violence after it occurs” (Hwang, 2016). Understaffing is identified as the single most

aggravating factor for workplace violence. “Staffing healthcare settings with the appropriate number and

skill mix of staff based on patient acuity is the number one action employers could take to prevent

workplace violence… staffing ratios are the key to both improving patient care and nurses’ health and
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safety” (Hwang, 2016). Hwang identifies other major risk factors as being crowded waiting rooms and

long waits, lack of security, isolated work spaces, a patient’s history of violence as well as their mental

and medical history.

Worker, Workplace, and Community/Environment Risk Factors for Workplace Violence in

Emergency Departments by Gordon L. Gillespie, Bunnany Pekar, Terri L. Byczkowski and Bonnie S.

Fisher, is a research article that examines workplace violence committed by patients and visitors and the

association of certain factors. The authors research found a correlation between verbal abuse, threats of

violence and physical assault.

“Given verbal abuse potentially being a precursor to work place violence escalation, prevention

efforts may need to focus more extensively on training ED employees to confront and mitigate

verbal abuse versus the study sites focus on training efforts to manage physically violent patients”

(Gillespie et al., 2015).

The authors research also found that registered nurses working in hospital-based emergency departments

experience verbal abuse and physical assault at a higher percentage than any other occupational group.

The authors make the suggestion that emergency departments employ mental health specialists to assist in

deescalating stressful situations that have the potential to turn violent.

Dealing With Workplace Violence in Emergency Primary Health Care; A Focus Group Study by

Tone Morken, Ingrid H. Johansen and Kjersti Alsaker, is a research article that utilizes a focused group

study to examine how emergency primary health care workers have dealt with threats of violence. “A

better understanding of how personnel deal with violent incidents may point to factors the emergency

primary care organization should pay attention to in preventing and managing workplace violence”

(Morken, Johansen & Alsaker, 2015). The authors research found four themes among the focus groups

responses. “For anticipating or dealing with incidents of threats or violence within the system: (1)

minimizing the risk of working alone, (2) being prepared, (3) resolving mismatch between patient
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expectations and the service offered, and (4) supportive manager response” (Morken et al., 2015). This

research article concludes with citing the need for further studies to assess the effectiveness of the four

themes identified.

The Participant’s Perspective: Learning From an Aggression Management Training Couse for

Nurses. Insights From a Qualitative Interview Study, by Birgit Heckemann, Helga E. Breimaier, Rudd

J.G. Halfens, Jos M.G.A. Schols, and Sabine Hahn, is a research study that examines the benefit of

aggression management training courses for nurses. This research study is unique, in that, not many

studies examine the benefit of training courses. The researchers found that, “the training refreshed

existing knowledge, or nurses recognized that they had previously been using de-escalation strategies

intuitively” (Heckemann, Breimaier, Halfens, Schols & Hahn, 2016). Results also indicated that the

aggression management training increased nurses’ situational awareness, increased nurses’ emotional

self-management, and increased nurses’ confidence in dealing with potential threatening situations.

In A Framework for Translating Workplace Violence Intervention Research into Evidence-Based

Programs, authors Kate McPaul, Matt London and Jane Lipscomb, review existing guidelines, scientific

evidence, and locally generated practice to develop a framework that can be used to assist health care

facilities in developing their own violence prevention programs. Their framework falls within the scope

of existing state laws that mandate comprehensive workplace violence prevention programs. The

Guidelines for Prevention of Workplace Violence in Health and Social Services, which is a United States

Occupational Safety and Health Administration (OSHA) guidance document, is also cited as a heavy

influencer of the framework. The authors evaluated previously established violence prevention programs

that were designed based on federal OSHA guidelines. The authors reviewed surveys that had been

conducted by the Bureau of Labor Statistics. The authors also studied The Veterans Health

Administration’s (VHA) computerized patient medical record system for flagging violent behavior and

the staff education curriculum on training for violent behavior. The VHA also makes use of Disruptive

Behavior Committees, which utilizes specialists in reviewing mental health care plans. After a thorough
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explanation of the research, the authors explain their framework. The authors define comprehensive

workplace violence prevention as, “programs that demonstrate evidence of management support and

employee involvement; include a hazard assessment; utilize violence controls that are based on the hazard

assessment (i.e. data driven); include employee training; and incorporate periodic evaluation” (McPaul,

London & Lipscomb, 2013).

Analysis

While available research utilizes numerous methodologies to extensively evaluate risk factors for

violence directed towards registered nurses, few studies evaluate the effectiveness of violence prevention

programs. While most state laws do not require violence prevention programs for its health care staff, it

is in the best interest of the facility to do so. A substantial gap in this field of research is that the only

state with mandatory reporting of violent incidents is the State of Washington. Researchers agree that

incidents of violence directed towards health care staff is grossly underreported.

Recommendations

There is a need for future research to evaluate the effectiveness of violence prevention programs

by using multiple methodologies. Contingent upon this bill becoming law, a future research title could

be: Evaluating the Workplace Violence Prevention for Health Care and Social Service Workers Act at the

Bedside, A Registered Nurses Perspective. Interviews conducted with bedside nurses could be used to

gain insight on whether or not the programs are protecting those they were meant to protect.
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References

American Nurses Association. (2016, February 03). Workplace violence. American Nurses Association.

Retrieved on July 03, 2019 from https://www.nursingworld.org/practice-

policy/advocacy/state/workplace-violence2/

Gillespie, G. L., Pekar, B., Byczkowski, T. L., & Fisher, B. S. (2017). Worker, workplace, and

community/environmental risk factors for workplace violence in emergency departments.

Archives Of Environmental & Occupational Health, 72(2), 79–86. Retrieved on September 20,

2019 from https://www.ncbi.nlm.nih.gov/pubmed/26980080

Heckemann, B., Breimaier, H. E., Halfens, R. J. G., Schols, J. M. G. A., & Hahn, S. (2016). The

participant’s perspective: learning from an aggression management training course for

nurses. Insights from a qualitative interview study. Scandinavian Journal Of Caring

Sciences, 30(3), 574–585. Retrieved from

https://www.ncbi.nlm.nih.gov/pubmed/26753805

Hwang, L. (2016). Unnecessary risk. National Nurse. 112(3), 14-19. Retrieved from

http://search.ebscohost.com.libproxy.dtcc.edu/login.aspx?direct=true&db=c8h&AN=118972973

&site=ehost-live

McPhaul, K. M., London, M., & Lipscomb, J. A. (2013). A Framework for Translating

Workplace Violence Intervention Research into Evidence-Based Programs. Online

Journal of Issues in Nursing, 18(1), 1. Retrieved on October 4, 2019, from

http://ojin.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/Tabl

eofContents/Vol-18-2013/No1-Jan-2013/A-Framework-for-Evidence-Based-Programs.html
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Morken, T., Johansen, I.H., & Alsaker, K. (2015). Dealing with workplace violence in emergency primary

health care; a focus group study. BMC Family Practice, 16, 51. Retrieved on September 12,

2019 from http://www.ncbi.nlm.nih.gov/pubmed/25929751