Five Urgent Steps To Address Violence Against Nurses In The Workplace

A new bargaining chip appeared on the table as hospital employees in Iowa negotiated a new contract with the University of Iowa Hospitals and Clinics—protection from patient attacks. Iowa’s increase in non-fatal workplace injuries and illnesses among registered nurses echoed national trends with a 32.9 percent increase in violence-related workplace injury and illness in nurses from 2019 to 2020. Across the US, violent assaults in health care are rising; three nurses were killed at work in the fall of 2022. One hospital-based analysis shows two nurses are assaulted every hour. The statistics are alarming and disturbing.

The COVID-19 pandemic increased patient violence toward nurses and health care workers; in one survey, 27 percent of nurses reported more incidents during the pandemic than previously.

This burden is particularly heavy in psychiatric settings: According to 2018 Bureau Of Labor Statistics data, the US incidence rate of nonfatal intentional injury by other person, was nearly 10 times higher in psychiatric hospitals compared to all hospitals (124.9 versus 12.8 per 10,000 full-time workers). Nor is it unique to the United States. One study from a large mental health center in Israel found that nearly all (98 percent) of psychiatric nurses reported patient violence exposure. Another study of health care workers in two Australian brain injury hospital wards found the same disturbing result.

We write today, as psychiatric mental health nurses and workplace violence and nursing workforce researchers, to express our alarm: Our nurse colleagues aren’t safe at the bedside. The American Psychiatric Nurses Association reports that fewer than two-thirds of nurses report feeling either safe or very safe at work. As nurses reported in last year’s “National Plan for Health Workforce Well BeingNational Academy of Medicine, violent injury of nursing staff by patients results in nurses’ short- and long-term disability, psychological stress, post-traumatic stress disorder, burnout, reduced quality of care, errors, and accidents.

Some health care organizations have independently employed various strategies to confront these challenges, but with varying quality and comprehensiveness; they have been inconsistent across settings.

How can we more effectively protect nurses against patient violence?

In this article, we propose a five-pronged approach—key actions that we believe must happen immediately and simultaneously—to protect psychiatric nurses and all nurses and staff from patient violence. Such synergy will require coordination among legislators, health regulators, health care organizations, data systems, and nursing practice and educational entities.

1. Enact Comprehensive Federal Legislation

In each new Congress since 2019, Senator Tammy Baldwin (D-WI) and Representative Joe Courtney (D-CT) have introduced the Workplace Violence Prevention for Health Care and Social Service Workers Act, which would require the Department of Labor to address workplace violence in health care, social service, and other sectors. But the legislation has consistently failed to gain the traction necessary to become law. It was introduced again in this Congress, and we believe it is long past time for it to be enacted as law.

Under the legislation, the secretary of Labor would have one year to issue an interim final standard from the Occupational Safety and Health Administration (OSHA) requiring employers in health care and social services agencies to implement comprehensive violence prevention plans and to carry out other activities or requirements to protect health care workers, social service workers, and other personnel. Enforcement would be consistent with other violations of OSHA regulations, and whistle-blowers would be protected from retaliation, an essential preventative measure for non-compliant health care entities.

2. Emphasize Quality Indicators That Elevate Efforts To Protect Staff From Harm

Health care accrediting agencies have so far failed to give equal attention to the effect of violence on the workforce. For example, the quality and safety standards for psychiatric facilities currently in use by the Joint Commission (Hospital-Based Inpatient Psychiatric Services) do not include an indicator of patient assault; nor has any kind of clear mandate for nurses to report violent incidents been included in unit-level violence prevention plans and trauma-informed de-escalation training programs. This gap persists despite the interrelatedness of staff and patient safety.

Therefore, we believe that—the Big Five accreditors of hospitals and psychiatric facilities—Utilization Review Accreditation Commission, the National Committee for Quality Assurance, The Joint Commission, the Commission on Accreditation of Rehabilitation Facilities, and the Council on Accreditation —should immediately include data-supported indicators in accreditation standards that protect nurses and staff in psychiatric care settings from injury by patients. What is more, they should specify sanctions for failure to comply with these indicators—targeted penalties for allowing conditions that have been shown to increase the risk of injury to psychiatric nurses and staff.

3. Strengthen Data Systems To Better Monitor Worker Exposure To Aggressive Events

Institutional safety committees should collect and use data shown to deepen our understanding of aggressive acts—including staff-to-patient ratios, patient type and severity, patient and staff turnover rates, and overall incident reporting. These data—including measures of system-level precursors—should be examined within the larger context of external events—such as societal trends and violence. By monitoring all aggressive events, from verbal and physical events to those that result in nurse injury, health systems can elevate best practices for prevention and post-incident care. They can also better understand the recurring characteristics that run like a common thread through frequent kinds of events. These data can also help advance those interventions shown to help resolve aggression at lower levels of severity. This kind of important knowledge is necessary to improving prevention.

Nearly all current methods of monitoring aggressive events don’t include information on worker exposure. The lone exception is worker injury reports, which include only a very small portion of all aggressive events and don’t provide data accurately enough to understand the impacts of aggression on workers.

As access to data improve, severe events should receive immediate analysis followed by clear next steps to address patient and staff needs, safety demands, treatment planning, root cause identification, and safety planning to prevent future events. And safety committees need sufficient agency within their own institutions to implement change. The Cleveland Clinic is doing this right by declaring a zero-tolerance policy on violence against health care workers and visitors, highlighting this policy with signage in high-visibility areas throughout the hospital. The clinic use several sources of data to track and analyze violent events, including its own Safety Event Reporting System. The message is clear: Safety, prevention and a uniform response to violence is a collaborative effort involving leaders at every level.

It is against this backdrop that we call on hospital accrediting bodies to require hospital and health systems to define a comprehensive plan for measuring aggressive events including the measurement of worker exposure to those events.

4. Improve Reporting Of Workplace Violence

When nurses and nursing staff underreport acts of aggression, it sets the stage for that aggression to escalate. Within a female-identified nursing culture, values such as caring and conflict avoidance can perpetuate an unhelpful silence about the nature and frequency of aggressive acts. In some organizations, institutional management and policies may implicitly reinforce such silence and prevent the kind of essential collaboration that is necessary to reduce violence. And it poses serious obstacles to the development of safety standards, mandated best practices including de-escalation training, evidence-gathering about preventative measures, and safe staffing minimums.

Violence perpetrated by patients doesn’t tend to arise solely from a single cause or discrete patient characteristic but rather from the interplay of stressors and vulnerabilities at the health unit or system level that interact with a distressed patient at a given point in time. Understanding and learning to recognize such subtle dynamics—including the vital importance of reporting aggressive acts and the effective deployment of de-escalation and preventive strategies—are key components of psychologically and physically safe work environments.

We therefore believe that health care organizations must invest systemwide in management training initiatives aimed at building safe work cultures. They must also prioritize aggression reporting and reduction as mandated by legislation and accrediting agencies. This includes incentives and training that set expectations for reporting by nursing staff and their participation in decision making. Likewise, systems leaders must commit to implementing and evaluating interventions designed to reduce systemic and unit-based violence.

5. Hold Educational Institutions Accountable For Teaching About Quality And Safety Standards That Protect Nurses And Staff From Injury

Psychiatric care systems are staffed with nurses who haven’t been equipped to respond to the current level of aggression in patient populations. To prepare nurses for contemporary practice, nursing education must convey the full spectrum of quality and safety standards that emphasize the synergy between nurse and patient safety. Dangerous working conditions represent system failures, not individual failure. Yet, the emphasis on individual accountability and impulse to accept blame when something goes wrong begins in pre-licensure education. Too many nursing students are not taught about the intentional action they must take to recognize, document, and intervene to protect staff safety.

We believe that accreditors of baccalaureate pre-licensure programs such as the American Association of Colleges of Nursing (AACN) must provide detailed standards to create a culture of self-preservation and intentional action among the nursing workforce. Specifically, programs should demonstrate adherence to AACN Essentials Domains 5 (Quality and Safety) and 8 (Professionalism and Professional Values) standards by viewing patient violence toward nurses and staff as a serious work environment hazard. Fundamentally, this priority is about preparing graduates to act effectively to prevent and respond to incidents.

Act Now

As workplace violence researchers and mental health academic nurses, we have leveraged our alarm and collective skill sets to distill the research, administrative, practice, and policy issues into this five-pronged approach to begin to solve the problem of violence against nurses by patients. We now urge legislators, health regulators, health care organizations, data systems, educational entities, and nurses at all levels of practice to act now to prevent further injury and death to psychiatric nurses and staff.

(This story originally appeared in HealthAffairs.)