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Workplace Violence
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Violence Across the Lifespan: Implications for Critical Care
Workplace Violence Prevalence, Prevention, and First-Line Interventions Michael L. Williams, MSN, RN, CCRN, and Kathleen Robertson, MS, RN
W orkplace violence represents a wide range of behaviors that can occur in any workplace setting resulting in a threat to safety, health, and well-being. Violence inflicted on employees may come from many sources including patients, families, or third parties. Workplace violence is becoming more common and widely publicized.8• 11 It is important for critical care nurses to understand the prevalence of workplace violence, strategies to prevent it, and first-line interventions. Nurses and critical care nurses are at high risk for violence in the workplace given the crisisoriented nature of their work in intensive care units (ICU). Critical care nurses, however, are also uniquely positioned to prevent and intervene in potentially violent situations. This article describes the prevalence of workplace violence, suggests strategies for violence prevention in the workplace, and offers intervention strategies for violent situations.
From Thoracic Surgical Nursing (MLW), and M-Works Employee Assistance Program (KR), University of Michigan Health System, Ann Arbor, Michigan
What Is Workplace Violence? Violence is a complex phenomenon with multiple definitions and multiple causes. Perhaps the most common definition of violence is "the intentional use of force against another person or against oneself which either results in or has a high likelihood of resulting in injury or death.''9a Although this definition is descriptive, because one can easily imagine a battered individual, this definition does not account for psychological injury that can result from verbal insult; nor does it include violence aimed at physical property. A clear distinction between an escalating crisis and a violent crisis does not exist. It is generally accepted, however, that workplace violence encompasses both physical and psychological injury to an individual or group, as well as actions that result in damage to persons or property. There are two forms of violence that occur in hospital settings: (I) acts of physical violence and (2) acts of aggression. Acts of physical violence can be an intentional or a directed
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physical act that causes injury to another person, such as a supervisor, co-worker, customer, student, or the general public. Acts of physical violence can also include reckless damage to property. The second form of violence that can occur within the work setting is an act of aggression. Acts of aggression are a form of violence that can include verbal or physical actions intended to create fear or apprehension. Acts of aggression usually come in the form of jokes, pranks, or intimidating vague threats, such as "you better watch out" or "do you remember that act of violence at such and such institution?" Acts of aggression include inappropriate and rude behavior that disrupts organizational operations. With both forms of violence, acts of aggression and acts of physical violence, the scope of behaviors is wide. The range of behaviors for aggression and violence creates a challenge to workers; some behaviors are well tolerated, whereas others are not. It is similar to the sexual harassment issue; what might constitute sexual harassment in one situation may not be considered sexual harassment in another situation. Each situation needs to be evaluated individually within the context of all of the facts. Even though we are required to have some specific policies, in general the guideline is zero tolerance of all fonns of violence. 5 Regardless of the setting (factory, hospital, clinic, or other), there has to be zero tolerance for acts of aggression and acts of violence. It is also important to note that what constitutes violence has been changing for health care providers; thus, what was once considered a joke or a prank can in fact be considered threatening or intimidating to another individual. We have to examine each of those incidences and say "what was that about?" and examine what was intended and what was perceived. Nevertheless, violent behaviors cannot be tolerated.
1 million Americans are assaulted while working or on duty, according to the Justice Department. On average, 20 workers are murdered and 18,000 are assaulted each week. 7 Yet, it is unconunon to hear of the scope of workplace violence in the hospital setting. It is speculated that the incidence of workplace violence in hospitals is grossly underreported because there is a perception that violence within health care is simply a part of the job.9 A 1989 report showed that nursing staff at a psychiatric hospital sustained 16 assaults per 100 employees per year, compared with 8.3 injuries of all times per 100 full-time workers in all industries.9 Additionally, from 1983 to 1989 there were 69 registered nurses killed at work, and between 1980 and 1990 there were 106 occupational violence-related deaths among health care workers. 4 In other words, from 1980 to 1990 on the average there were 10 violence-related deaths per year. Furthermore, a report of workplace assaults indicated that "nurses aides, nurses, police officers and secondary school teachers ranked among the most dangerous jobs for women." 13 These statistics are simply the proverbial tip of the iceberg, because they do not account for the actual incidences of violence, only those resulting in death. Although incidences of workplace violence in the United States Postal Services and factories (most recently Ford Motor Company in Michigan) receive wide media attention, 3 assaults occur in health care and social service industries more often than in any other industry.14 Perhaps because hospitals are perceived and market themselves as safe havens for ill individuals, there is greater tolerance for violent behavior given the emotional stress that individuals, families, and visitors are experiencing. Nevertheless, workplace violence is prevalent. In fact, a survey by Northwestern Mutual Life Insurance showed that one out of four employees (25%) in all industries was harassed, threatened, or attacked from July 1992 to June 1993.6
The Prevalence of Workplace Violence
Workplace Violence in Hospitals
Workplace violence in nonhospital settings has been highly publicized. Each year nearly
Although acts of aggression and acts of violence are the same despite the setting, there
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are situational and circumstantial factors in hospitals and clinics that make workplace violence unique in those settings. For one, there is unrestricted movement of persons from one place to another; patients, families, and other visitors move quite freely throughout the health care institution with little or no limitations. There is also an increase in the number of drug abusers, gang members, individuals with a history of violence, individuals with previous records, and alcohol-dependent persons who are entering hospitals in need of health care. This situational circumstance simply puts hospitals and clinics at higher risk for violent situations. Others factors that put hospitals at risk are also situational. Trauma patients may have been traumatized because of a violent act or there could have been alcohol or drug abuse that caused the traumatic event. Patients, or even family members, may have been so traumatized by the event that caused hospitalization that their ability to cope is exceeded, and their potential for violence is heightened. Distraught family members come into our health system and we need to be prepared to assist them in their stressful condition. People bring who they are into a health care situation. If an individual is typically impatient, a prolonged emergency department wait will exacerbate their frustration and escalate an already stressful situation. Additionally, the patient's personality is not necessarily known to us. Not knowing the personality of the person and their typical behaviors, as well as their tolerance for frustration, puts health care institutions at risk for violent behaviors. If a person has a history of alcohol abuse, mental illness, or other condition that predisposes them to violent behaviors, they pose a risk for that workplace. Because of our health care imperative to provide care to ill individuals, including those who abuse alcohol and those who suffer from mental illness and other conditions, health care institutions have a disproportionate number of individuals predisposed to violent behaviors. Health care institutions are thus at much greater risk for violence than most other businesses.
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Societal changes, such as increased access to handguns; changes in the mental health system; the prevalence of drug use; and perhaps more global societal changes, such as changes in family and community support, may also play a role in workplace violence. The increase in workplace violence also stems from the prevalence of handguns and other weapons in our society. In fact, all of society is at risk because of the increased access to handguns. Patients and families who have access to handguns and weapons pose even more risk than those with limited or no access to handguns. There is also an increased number of acute and chronically mental ill patients with the right to refuse medication or hospitalization, unless they are a threat to themselves or others, who are living in the community, whereas at one time they were housed in state institutions. The availability of drugs and money at hospitals is another issue that places hospitals at higher risk for violence. Clinics and pharmacies are likely targets for robberies because of the availability of drugs. Although there are some theories that attribute the lack of the nuclear family, changes in community support to individuals residing within those communities, and changes in religious practices to an increase in violence in society, there is no conclusive evidence to suggest definitive strategies or solutions. A relatively recent factor that puts health care organizations at higher risk for violence is the downsizing of the health care industry. Although many other businesses have seen downsizing over the past few years, the changes in health care delivery appear ferocious. Societal changes have resulted in concerns over job security and professional identity for all citizens, but these changes have been particularly stressful to health care workers. These changes include the following: • The information supply available to us doubles every 5 years • There has been more information produced in the last 30 years than the previous 5000 years • In the 1960s almost one half of all workers in industrialized countries were in-
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volved in production (helping to make things) • Currently, an estimated two thirds of US employees work in the services sector and knowledge is becoming our most important product • Less than half the workforce in the industrial world will hold conventional fulltime jobs in organizations by the beginning of the twenty-first century; full-timers or insiders will be the new minority • In 1991, nearly one out of three American workers had been with their employer for less than a year, and almost two out of three for less than 5 years • During the decade of the 1980s, a total of 230 companies (46%) disappeared from the Fortune 500 • Two million jobs were eliminated in the 1980s, 1 million of them in middle management • More than 85% of the Fortune 1000 firms downsized their white collar workforce between 1987 and 1991 • Eight million people lost their jobs between 1982 and 1989 • In the health care sector, the American Hospital Association data indicate that there were 650 hospital consolidations between 1994 and 1995, and that number will double between 1995 and 1996. • R. Clayton McWhorter, the CEO from Health Trust, was quoted as projecting that "if inpatient utilization trends continue to drop, more than 1/3 of the 925,000 beds will no longer be needed. This would force the closure of as many as 2,500 hospitals." (Gaucher E, personal communication, 1996.) nus is a relatively new risk factor for health care institutions, but it is real for many regions of the country. If an employee's identity is wrapped up in their job and they are not connected to family, their community, or some type of support network, and are "redesigned" or eliminated from the organization, there is a higher risk of having a disgruntled or angry employee. Brought on by economic conditions, violent incidents are more likely to occur in
workplaces where employees feel they have little or no control. There is a belief by some that the number of violent workplace incidents will continue to increase as members of the baby boom generation confront a world of dim possibilities. The result of downsizing companies as lean and mean new organizations is an environment in which workers are asked to do more with less and from which they are unable to escape to another good paying job. This is a formula for creating tension and anxiety in the workplace. Yet, as health care institutions downsize, the public's expectation of excellence in health care services remains. When patients and families walk through the doors of the health care organization, they expect that they will be cared for immediately and superbly. With the restructuring of health care delivery services, however, resources to meet these expectations are stretched thin or do not exist. The business of health care has made it much more complicated for practitioners to provide services. The discrepancy between patient expectations and services received further exacerbates a stressful and potentially violent situation. The entries for health care services are particularly critical places (through the emergency department, through a clinic, direct admission to an ICU, and so forth) where we have to increase communication among health care providers about the behavior of the individual and significant others that leads us to believe they are at high risk for violent actions.
Preventing Workplace Violence Workplace violence will continue to happen, but by heightening awareness to prevention strategies critical care nurses can assist themselves and their employer in detecting potentially violent situations and in responding therapeutically to a violent situation. Prevention strategies include • Education • Training of supervisory personnel • Assessing threats and potentially violent persons
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• Managing an escalating crisis • Fair treatment to employees • Access to a grievance and appeal process Each of these approaches to workplace violence prevention is important, but perhaps the most important prevention strategy is the education of all employees about awareness and conflict management. Additionally, education regarding the prevalence of workplace violence, the role of the employee, and strategies for managing an escalating crisis are important. It is crucial that employees be attuned to the following warning signs of potentially violent behaviors and to report them to their supervisor for further assessment and intervention: • Making threats (direct or indirect) to seek revenge, obsessive focus on a grudge • Comments or interest in weapons, death, or other violent situations • History of violence or conflicts with authority • Suspected alcohol or drug problems • Exhibiting paranoia, depression, or bizarre behavior • Change in work behavior or work status (interpersonal conflicts, attendance, downsizing, grievance problems, denied promotion, termination • Denied claims (workers compensation, other suits • Recent history of major stress or family problems • Obsession (romantic or hate) with another employee Supervisory training regarding potential violence should include threat assessment, incident management, chain of command, and applicant screening. Supervisors, like employees, should follow the zero-tolerance policy and also the duty to warn policy that specifies that the institution has an obligation to warn any or all individuals at known risk of violence by another person. Assessing threats and potential violence is not easy; however, it is a critical component of violence prevention. It is imperative that critical care nurses who overhear or participate in conversations that include threats of violence or injury evaluate the individual's risk for violence. Pa-
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tients, visitors, and co-workers who exhibit behaviors that are typical of an escalating or violent person should be treated as a potentially violent individual. By recognizing a potentially violent or violent person, employees are readied for action. Often, with little intervention, an escalating person can be de-escalated quite easily. Frequently, an escalating person simply requires supportive and helpful communication, whereas the violent person requires one to take control and prevent injury. With an escalating person, it is important to keep a safe distance (3 to 6 ft preferably); avoid invasion of personal space (which tends to increase anxiety); avoid challenging stances (hands on hips, face to face); control the tone, volume, and rate of your communication; use empathetic listening skills; and to not agree with distortions or argue with the person. With a violent person, actions are aimed at protecting individuals within the environment. It is important to make a rapid assessment of the environment (who is a potential victim, location of exits, presence of a safe room, and so forth); call for assistance; determine who is in charge; and implement the plan (Table 1). In this situation, it is important to speak briefly, clearly, and firmly and to protect individuals at risk for violence. Treating employees fairly and with compassion can also help avoid potentially violent situations. As noted previously, it is often the employee who feels little or no control over his or her environment who is at risk for becoming violent. Developing fair treatment practices, including access to grievance and appeal processes, is a strategy that helps employees feel they are being treated fairly. Random acts of violence cannot be prevented entirely; they will continue to happen. 2 Most acts of workplace violence, however, are not random. Often there is a pattern of behavior that has led to the actual act of violence. By recognizing those patterns, being committed to the well-being and safety of employees, and developing workplace violence prevention policies, employees (along with employers) can create an environment in which the risk of violence is minimal. Every
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Escalating Person
First-Line Interventions for Workplace Violence Violent Penton
Appearance
Clenching jaw Narrowed eyes Frowning Anxious Clenched hands Looks angry and upset Face becoming reddened Beginning to perspire
Clenched jaw Piercing stare Reddened face Narrowed, glaring, or darting eyes Agitated Fearful or angry expression Vein standing out Perspiring heavily
Speech
Tremulous Loud voice Swearing Muttering Sarcastic
Inappropriate affects Shouting Repetitive speech Swearing Rambling
Movements
Exaggerated movements Nervous energy Gesturing Pacing Wringing hands Instructive
Pacing Pounding Making fists Tense muscles Exaggerated movements
Behaviors
Overly sensitive Irritable Crying Hostile Demanding Acting strangely Obnoxious
Hostile Threatening Belligerent Confused Suspicious Pounding Throwing Hitting Pushing Kicking Jabbing
From Kettley J, Rizzo J (eds): Preventing Worllplace Violence: A Training Manual. Ann Arbor, Ml, University of Michigan Health System, 1994, p 54; with permission.
employee must believe in the zero-tolerance policy and act accordingly. Because violence has become quite commonplace, every employee, including the critical care nurse, should be prepared, however, to respond to a violent act within their setting. Preventive strategies alone are not sufficient; a crisis response plan is also necessary.
Everyone should expect violence to occur within their workplace. Some people believe that hospitals and businesses should develop universal precautions for violence, proposing that violence should be expected and prepared for in any setting. Despite the heightened awareness for violence prevention and a clearly articulated and rehearsed violence prevention program, violence may still occur. Thus, it is important that employees be prepared to act in response to violence so that the negative outcomes of violence can be minimized. There are four basic intervention strategies that can be used to act in response to violence. These strategies include • De-escalating aggressive behaviors • Self-protection techniques • Protective equipment and alarm systems • Critical incident debriefing and follow-up Without question, the best weapon against violence is good verbal diffusion skills. Many violence prevention programs focus on establishing helpful communication skills with the perpetrator of violence. Methcxls of communication that have been found to be helpful in potentially violent situations include reflecting, clarifying, sununarizing, informing, and focusing. Useful straightfotward statements, such as "you look angry," also helps to focus on the feelings of the person. It is clear that this is the moment of truth, and expertise in interpersonal communication is paramount to a successful outcome. Most hospitals have developed threat assessment or violence prevention teams that are available to assist in aggressive or violent situations. Employees of health care institutions should be aware of their availability and use them to their fullest. Nurses and physicians may also lack expertise in therapeutic communication when working with aggressive or violent individuals; using these consultants is the wisest act possible. "Too often, physicians (and nurses) assume they have the expertise and skill necessary to handle these matters themselves. Difficulties arise when
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the physician (or nurse) lacks experience, or ignores or denies the potential seriousness of a patient threat or act of violence." 10 Deescalation skills are not innate; nor are they routinely taught in many medical or nursing schools. It should not be assumed that a physician or nurse is the most optimally skilled individual to cope with a potentially violent situation (Appendix). Yet, de-escalation skills remain the most helpful action during an act of aggression or violence. If verbal diffusion skills are insufficient to thwart violent behaviors, employees should initiate self-protection techniques. These activities are aimed at protecting oneself and others in the environment from great harm. First and foremost, activate your emergency system and report your name, location, and the "who, what, where and when" of the situation. It may be advisable to have someone other than yourself activate your emergency system; a key phrase or password may be helpful to relay your need for assistance without escalating the disgruntled individual. Direct the adversaries to leave the scene of a confrontation, but do not try physically to force a person to leave. Escape, hide if not already seen, or cover up if injury is likely and make every possible effort to get others out of the immediate area while positioning yourself, if possible, so that an exit route is readily accessible. Never attempt to disarm or accept a weapon from the person in question. Never challenge, try to bargain with a threatening individual, or make promises you cannot keep. If a weapon is involved, calmly ask the person to put it in a neutral location while you continue to talk with him or her. Do not argue, threaten, or block their exit. Protective equipment and alarm systems may also be used in violent situations. Seclusion rooms, bullet-proof enclosures, and other equipment may be used if necessary. Metal detectors may be required in some settings. Developing and using an appropriate alarm system (a password or key phrase) or a panic button, such as those used in convenience stores, may be necessary. Suiveillance cameras can be used and most hospitals have them in place. It is important not to become
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overly confident in the security that surveillance cameras provide, because having the cameras does not ensure that someone is watching them at all times. Last and perhaps most important is the critical incident debriefing or follow-through of the situation. To regain the trust and security of employees in a setting that has experienced workplace violence, it is important to demonstrate sensitivity to the trauma that has occurred and steps aimed at preventing further violent acts. It is important that the organization develop, announce, and implement a plan that takes employees' welfare seriously; establish who will conduct the investigation of this attack and who will be involved; and refer the individual to a staff assistance program if emotional, mental, or psychiatric conditions are suspected. It is also important to make arrangements to secure the building (rekey office doors, retrieve an employee's keys or limit computer access, post photos of persons not permitted to return to work, and alert employees of the perpetrator's restrictions) as well as to provide reassurance to individuals, families, and co-workers.
Workplace Violence and Health Professionals
Stress and violence in the workplace is not a new phenomenon. As health care professionals, however, we have been socialized to believe that the inability to cope with a problem is a taboo subject. Those individuals who are unable to cope effectively are viewed defective, weak, or in need of assistance. Yet any person has the potential for being overwhelmed with stress. Critical care practitioners, including critical care nurses, excel at always being in control and some suggest that critical care practitioners try to control life and death. Critical care nurses are particularly prone to the belief that the inability to cope is an individual weakness. But because of this belief, critical care nurses are at great risk for devaluing or missing cues that someone is overwhelmed and coping poorly. By not facing up to the problems of stress (and critical care
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units are truly stressful envirorunents), greater problems may result. Hospitals, clinics, and other health care systems need to embrace a culture that values the well-being (both physical and emotional) of their patients, visitors, and employees. They need to create frameworks for effective threat assessment and crisis response plans. They need to open up areas of communica-
tion and to link resources to provide violence education. Health care workers need to do a better job of making sure that they increase communication of what behaviors they see around the patient as he or she is coming through the door. By giving information to each other about potentially violent situations, we empower ourselves to prevent violent behavior.
SUMMARY
Workplace violence is increasing, but through education, prevention, and managing escalating crlses, critical care nurses can help to minimize the negative consequences of violence. Critical care nurses are particularly prone to acts of aggression and acts of violence due to the stressful environment for them, their families, and their patients. Developing violence prevention skills and interpersonal communication skills, not always highly valued in a critical care environmei:lt, are important steps in deterring workplace violence. Although not all incidents of workplace violence can be prevented, recognizing the individual at risk for violence and intervening on the behalf of all involved is a responsibility of every employee including the critical care nurse.
REFERENCES 1. Brown SM: The impact of violence on physician practice. Forum http://222.rmf.org:80/w3451.hunl., 1995, pp 1-3 2. Federal Protective Service: What you should know about coping with threats and violence in the federal workplace. http://www.gsa.gov/pbs.fps/fpsl.hunl 1996, pp 1-6 3. Fein RA, Vossekuil B, Holden GA: 'Threat assessment: An approach to prevent targeted violence. http:// www.ncjrs.org/txfiles/threat.txt, 1995, pp 1-11 4. Goodman RA, Jenkins EL, Mercy JA: Workplacerelated homicide among health care workers in the United States, 1980 through 1990. JAMA 272:16861688, 1994 5. Guardian Security Services: Violence in the workplace: A white paper. http://www.stayout.com/ violence/html, 1995, pp 1-5 6. Kenley J, Rizzo J: Managing Violence in the Workplace: A Training Manual. Ann Arbor, Ml, University of Michigan Health System, 1994 7. Laurent A: Short fuse. http://www.govexec.com:80/ features/1296st.html, 1996, pp 1-9 8. National Crisis Prevention Institute: Good verbal diffusion skills can be your best weapon. http://
www.execpc.com:80/-cpVcoweb.hanl., 1995, pp 1-2 9. OSHA 3148: Guidelines for preventing workplace violence for health care and social service workers. http://www.osha.gov/oshpubslwodcplace, 1996, pp 111
9a. Richmond T. Violence lnleroentionsforPatients, Providers, and Public Po/tcy [video conference). New Orleans, LA: American Association of Critical Care Nurses; 1995 10. Satore Township: Violence in the workplace today. http://www.crl.com/-mikekeB/v6.hunl., 1996, pp 1-4 11. Schouten R: When patients threaten. Forum http:// www.rmf.org:80/w3452.html., 1995, pp 1-4 12. Taylor RW: The Rockem-Sockem workplace. http:// venable.com/wlu/rockem.hunl., 1996, pp 1-4 13. Timm HW, Chandler CJ: Combating workplace violence. http://orpheus.amdahl.com/ext/iacp/pskl. toc.hanl., 1996, pp 1-9 14. US Department of Labor: Guidelines for preventing workplace violence for health care and social service workers. Occup Health Saf 3148:1-30, 1996 15. Weiss}: Violence at work: Workplace dangerous for women. http://tradewave.com/galaxy/community/ safetyI assault-prevention/ apin/workwomen. hunl., 1996, p 1 Address reprint requests to Michael L. Williams, MSN, RN, CCRN 211 East Shawnee Street Tecumseh, Ml 49286
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APPENDIX A family received information from the patient in the adjacent room that their mother had been verbally if not physically abused by the nurse on the night shift. They were very concerned and expressed their concern to the day-shift nurse, who agreed to refer their concern to the nurse manager. The attending physician was notified and spoke with the family as well. The response of the physician was simply, ''you have to trust me. I assure you that nothing like that has ever happened in this unit. I work with these nurses all of the time and I can vouch for them." When the family requested to spend the night at the bedside, the attending physician simply responded, "that is against unit policy," and "you can't do that." The family members continued to become agitated and repeatedly stated that, given the information they had at hand, they were concerned for their mother's physical safety. The attending physician responded, "if you don't trust me, then you can transfer her to another facility." At this point, the clinical nurse specialist (CNS) was requested by the nursing staff to intervene. The family was invited into the conference room and asked to share their concerns. After listening to their concerns and restating their issues about the potential safety concern, they were assured that these allegations would be taken seriously and would be investigated fully. They were also assured that the nurse in question would not be permitted to care for their mother. Their anger at the manner in which the physician had interacted with them was verified.
The nurse manager and the CNS met with the physician to gather further information about the situation. The visiting policy was clarified; restricting families from staying the night in the ICU was not a part of the policy. The physician, nurse manager, and CNS agreed to meet with the family once again to help reassure the family. The physician reiterated his perspective that, "you must trust me," and "something like this wouldn't happen here." When challenged by the patient's daughter, the physician became verbally loud, arguing with her and again stating, "you can always transfer her somewhere elseI knew you were going to be a problem when I met you in my office before the surgery." At that point, the CNS intervened, first to stop the physician from escalating the family further and second to clarify each of their perspectives. The physician in fact felt it was important for the family to trust him, but rather than owning up to this need (his personal need to be trusted), he placed the onus on them. Second, it was agreed that none present could ever know what really occurred during the night before because none of them were present. It was also agreed that this was a serious allegation that would be fully investigated. Last, it was agreed that it was important to the family to ensure their mother's safety and allay their fears that they would be allowed to stay the night in the ICU or in the ICU waiting room, and make unannounced visits through the night.
os99-5885/97 $0.oo + .20
Violence Across the Lifespan: Implications for Critical Care
Workplace Violence Prevalence, Prevention, and First-Line Interventions Michael L. Williams, MSN, RN, CCRN, and Kathleen Robertson, MS, RN
W orkplace violence represents a wide range of behaviors that can occur in any workplace setting resulting in a threat to safety, health, and well-being. Violence inflicted on employees may come from many sources including patients, families, or third parties. Workplace violence is becoming more common and widely publicized.8• 11 It is important for critical care nurses to understand the prevalence of workplace violence, strategies to prevent it, and first-line interventions. Nurses and critical care nurses are at high risk for violence in the workplace given the crisisoriented nature of their work in intensive care units (ICU). Critical care nurses, however, are also uniquely positioned to prevent and intervene in potentially violent situations. This article describes the prevalence of workplace violence, suggests strategies for violence prevention in the workplace, and offers intervention strategies for violent situations.
From Thoracic Surgical Nursing (MLW), and M-Works Employee Assistance Program (KR), University of Michigan Health System, Ann Arbor, Michigan
What Is Workplace Violence? Violence is a complex phenomenon with multiple definitions and multiple causes. Perhaps the most common definition of violence is "the intentional use of force against another person or against oneself which either results in or has a high likelihood of resulting in injury or death.''9a Although this definition is descriptive, because one can easily imagine a battered individual, this definition does not account for psychological injury that can result from verbal insult; nor does it include violence aimed at physical property. A clear distinction between an escalating crisis and a violent crisis does not exist. It is generally accepted, however, that workplace violence encompasses both physical and psychological injury to an individual or group, as well as actions that result in damage to persons or property. There are two forms of violence that occur in hospital settings: (I) acts of physical violence and (2) acts of aggression. Acts of physical violence can be an intentional or a directed
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physical act that causes injury to another person, such as a supervisor, co-worker, customer, student, or the general public. Acts of physical violence can also include reckless damage to property. The second form of violence that can occur within the work setting is an act of aggression. Acts of aggression are a form of violence that can include verbal or physical actions intended to create fear or apprehension. Acts of aggression usually come in the form of jokes, pranks, or intimidating vague threats, such as "you better watch out" or "do you remember that act of violence at such and such institution?" Acts of aggression include inappropriate and rude behavior that disrupts organizational operations. With both forms of violence, acts of aggression and acts of physical violence, the scope of behaviors is wide. The range of behaviors for aggression and violence creates a challenge to workers; some behaviors are well tolerated, whereas others are not. It is similar to the sexual harassment issue; what might constitute sexual harassment in one situation may not be considered sexual harassment in another situation. Each situation needs to be evaluated individually within the context of all of the facts. Even though we are required to have some specific policies, in general the guideline is zero tolerance of all fonns of violence. 5 Regardless of the setting (factory, hospital, clinic, or other), there has to be zero tolerance for acts of aggression and acts of violence. It is also important to note that what constitutes violence has been changing for health care providers; thus, what was once considered a joke or a prank can in fact be considered threatening or intimidating to another individual. We have to examine each of those incidences and say "what was that about?" and examine what was intended and what was perceived. Nevertheless, violent behaviors cannot be tolerated.
1 million Americans are assaulted while working or on duty, according to the Justice Department. On average, 20 workers are murdered and 18,000 are assaulted each week. 7 Yet, it is unconunon to hear of the scope of workplace violence in the hospital setting. It is speculated that the incidence of workplace violence in hospitals is grossly underreported because there is a perception that violence within health care is simply a part of the job.9 A 1989 report showed that nursing staff at a psychiatric hospital sustained 16 assaults per 100 employees per year, compared with 8.3 injuries of all times per 100 full-time workers in all industries.9 Additionally, from 1983 to 1989 there were 69 registered nurses killed at work, and between 1980 and 1990 there were 106 occupational violence-related deaths among health care workers. 4 In other words, from 1980 to 1990 on the average there were 10 violence-related deaths per year. Furthermore, a report of workplace assaults indicated that "nurses aides, nurses, police officers and secondary school teachers ranked among the most dangerous jobs for women." 13 These statistics are simply the proverbial tip of the iceberg, because they do not account for the actual incidences of violence, only those resulting in death. Although incidences of workplace violence in the United States Postal Services and factories (most recently Ford Motor Company in Michigan) receive wide media attention, 3 assaults occur in health care and social service industries more often than in any other industry.14 Perhaps because hospitals are perceived and market themselves as safe havens for ill individuals, there is greater tolerance for violent behavior given the emotional stress that individuals, families, and visitors are experiencing. Nevertheless, workplace violence is prevalent. In fact, a survey by Northwestern Mutual Life Insurance showed that one out of four employees (25%) in all industries was harassed, threatened, or attacked from July 1992 to June 1993.6
The Prevalence of Workplace Violence
Workplace Violence in Hospitals
Workplace violence in nonhospital settings has been highly publicized. Each year nearly
Although acts of aggression and acts of violence are the same despite the setting, there
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are situational and circumstantial factors in hospitals and clinics that make workplace violence unique in those settings. For one, there is unrestricted movement of persons from one place to another; patients, families, and other visitors move quite freely throughout the health care institution with little or no limitations. There is also an increase in the number of drug abusers, gang members, individuals with a history of violence, individuals with previous records, and alcohol-dependent persons who are entering hospitals in need of health care. This situational circumstance simply puts hospitals and clinics at higher risk for violent situations. Others factors that put hospitals at risk are also situational. Trauma patients may have been traumatized because of a violent act or there could have been alcohol or drug abuse that caused the traumatic event. Patients, or even family members, may have been so traumatized by the event that caused hospitalization that their ability to cope is exceeded, and their potential for violence is heightened. Distraught family members come into our health system and we need to be prepared to assist them in their stressful condition. People bring who they are into a health care situation. If an individual is typically impatient, a prolonged emergency department wait will exacerbate their frustration and escalate an already stressful situation. Additionally, the patient's personality is not necessarily known to us. Not knowing the personality of the person and their typical behaviors, as well as their tolerance for frustration, puts health care institutions at risk for violent behaviors. If a person has a history of alcohol abuse, mental illness, or other condition that predisposes them to violent behaviors, they pose a risk for that workplace. Because of our health care imperative to provide care to ill individuals, including those who abuse alcohol and those who suffer from mental illness and other conditions, health care institutions have a disproportionate number of individuals predisposed to violent behaviors. Health care institutions are thus at much greater risk for violence than most other businesses.
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Societal changes, such as increased access to handguns; changes in the mental health system; the prevalence of drug use; and perhaps more global societal changes, such as changes in family and community support, may also play a role in workplace violence. The increase in workplace violence also stems from the prevalence of handguns and other weapons in our society. In fact, all of society is at risk because of the increased access to handguns. Patients and families who have access to handguns and weapons pose even more risk than those with limited or no access to handguns. There is also an increased number of acute and chronically mental ill patients with the right to refuse medication or hospitalization, unless they are a threat to themselves or others, who are living in the community, whereas at one time they were housed in state institutions. The availability of drugs and money at hospitals is another issue that places hospitals at higher risk for violence. Clinics and pharmacies are likely targets for robberies because of the availability of drugs. Although there are some theories that attribute the lack of the nuclear family, changes in community support to individuals residing within those communities, and changes in religious practices to an increase in violence in society, there is no conclusive evidence to suggest definitive strategies or solutions. A relatively recent factor that puts health care organizations at higher risk for violence is the downsizing of the health care industry. Although many other businesses have seen downsizing over the past few years, the changes in health care delivery appear ferocious. Societal changes have resulted in concerns over job security and professional identity for all citizens, but these changes have been particularly stressful to health care workers. These changes include the following: • The information supply available to us doubles every 5 years • There has been more information produced in the last 30 years than the previous 5000 years • In the 1960s almost one half of all workers in industrialized countries were in-
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volved in production (helping to make things) • Currently, an estimated two thirds of US employees work in the services sector and knowledge is becoming our most important product • Less than half the workforce in the industrial world will hold conventional fulltime jobs in organizations by the beginning of the twenty-first century; full-timers or insiders will be the new minority • In 1991, nearly one out of three American workers had been with their employer for less than a year, and almost two out of three for less than 5 years • During the decade of the 1980s, a total of 230 companies (46%) disappeared from the Fortune 500 • Two million jobs were eliminated in the 1980s, 1 million of them in middle management • More than 85% of the Fortune 1000 firms downsized their white collar workforce between 1987 and 1991 • Eight million people lost their jobs between 1982 and 1989 • In the health care sector, the American Hospital Association data indicate that there were 650 hospital consolidations between 1994 and 1995, and that number will double between 1995 and 1996. • R. Clayton McWhorter, the CEO from Health Trust, was quoted as projecting that "if inpatient utilization trends continue to drop, more than 1/3 of the 925,000 beds will no longer be needed. This would force the closure of as many as 2,500 hospitals." (Gaucher E, personal communication, 1996.) nus is a relatively new risk factor for health care institutions, but it is real for many regions of the country. If an employee's identity is wrapped up in their job and they are not connected to family, their community, or some type of support network, and are "redesigned" or eliminated from the organization, there is a higher risk of having a disgruntled or angry employee. Brought on by economic conditions, violent incidents are more likely to occur in
workplaces where employees feel they have little or no control. There is a belief by some that the number of violent workplace incidents will continue to increase as members of the baby boom generation confront a world of dim possibilities. The result of downsizing companies as lean and mean new organizations is an environment in which workers are asked to do more with less and from which they are unable to escape to another good paying job. This is a formula for creating tension and anxiety in the workplace. Yet, as health care institutions downsize, the public's expectation of excellence in health care services remains. When patients and families walk through the doors of the health care organization, they expect that they will be cared for immediately and superbly. With the restructuring of health care delivery services, however, resources to meet these expectations are stretched thin or do not exist. The business of health care has made it much more complicated for practitioners to provide services. The discrepancy between patient expectations and services received further exacerbates a stressful and potentially violent situation. The entries for health care services are particularly critical places (through the emergency department, through a clinic, direct admission to an ICU, and so forth) where we have to increase communication among health care providers about the behavior of the individual and significant others that leads us to believe they are at high risk for violent actions.
Preventing Workplace Violence Workplace violence will continue to happen, but by heightening awareness to prevention strategies critical care nurses can assist themselves and their employer in detecting potentially violent situations and in responding therapeutically to a violent situation. Prevention strategies include • Education • Training of supervisory personnel • Assessing threats and potentially violent persons
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• Managing an escalating crisis • Fair treatment to employees • Access to a grievance and appeal process Each of these approaches to workplace violence prevention is important, but perhaps the most important prevention strategy is the education of all employees about awareness and conflict management. Additionally, education regarding the prevalence of workplace violence, the role of the employee, and strategies for managing an escalating crisis are important. It is crucial that employees be attuned to the following warning signs of potentially violent behaviors and to report them to their supervisor for further assessment and intervention: • Making threats (direct or indirect) to seek revenge, obsessive focus on a grudge • Comments or interest in weapons, death, or other violent situations • History of violence or conflicts with authority • Suspected alcohol or drug problems • Exhibiting paranoia, depression, or bizarre behavior • Change in work behavior or work status (interpersonal conflicts, attendance, downsizing, grievance problems, denied promotion, termination • Denied claims (workers compensation, other suits • Recent history of major stress or family problems • Obsession (romantic or hate) with another employee Supervisory training regarding potential violence should include threat assessment, incident management, chain of command, and applicant screening. Supervisors, like employees, should follow the zero-tolerance policy and also the duty to warn policy that specifies that the institution has an obligation to warn any or all individuals at known risk of violence by another person. Assessing threats and potential violence is not easy; however, it is a critical component of violence prevention. It is imperative that critical care nurses who overhear or participate in conversations that include threats of violence or injury evaluate the individual's risk for violence. Pa-
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tients, visitors, and co-workers who exhibit behaviors that are typical of an escalating or violent person should be treated as a potentially violent individual. By recognizing a potentially violent or violent person, employees are readied for action. Often, with little intervention, an escalating person can be de-escalated quite easily. Frequently, an escalating person simply requires supportive and helpful communication, whereas the violent person requires one to take control and prevent injury. With an escalating person, it is important to keep a safe distance (3 to 6 ft preferably); avoid invasion of personal space (which tends to increase anxiety); avoid challenging stances (hands on hips, face to face); control the tone, volume, and rate of your communication; use empathetic listening skills; and to not agree with distortions or argue with the person. With a violent person, actions are aimed at protecting individuals within the environment. It is important to make a rapid assessment of the environment (who is a potential victim, location of exits, presence of a safe room, and so forth); call for assistance; determine who is in charge; and implement the plan (Table 1). In this situation, it is important to speak briefly, clearly, and firmly and to protect individuals at risk for violence. Treating employees fairly and with compassion can also help avoid potentially violent situations. As noted previously, it is often the employee who feels little or no control over his or her environment who is at risk for becoming violent. Developing fair treatment practices, including access to grievance and appeal processes, is a strategy that helps employees feel they are being treated fairly. Random acts of violence cannot be prevented entirely; they will continue to happen. 2 Most acts of workplace violence, however, are not random. Often there is a pattern of behavior that has led to the actual act of violence. By recognizing those patterns, being committed to the well-being and safety of employees, and developing workplace violence prevention policies, employees (along with employers) can create an environment in which the risk of violence is minimal. Every
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Escalating Person
First-Line Interventions for Workplace Violence Violent Penton
Appearance
Clenching jaw Narrowed eyes Frowning Anxious Clenched hands Looks angry and upset Face becoming reddened Beginning to perspire
Clenched jaw Piercing stare Reddened face Narrowed, glaring, or darting eyes Agitated Fearful or angry expression Vein standing out Perspiring heavily
Speech
Tremulous Loud voice Swearing Muttering Sarcastic
Inappropriate affects Shouting Repetitive speech Swearing Rambling
Movements
Exaggerated movements Nervous energy Gesturing Pacing Wringing hands Instructive
Pacing Pounding Making fists Tense muscles Exaggerated movements
Behaviors
Overly sensitive Irritable Crying Hostile Demanding Acting strangely Obnoxious
Hostile Threatening Belligerent Confused Suspicious Pounding Throwing Hitting Pushing Kicking Jabbing
From Kettley J, Rizzo J (eds): Preventing Worllplace Violence: A Training Manual. Ann Arbor, Ml, University of Michigan Health System, 1994, p 54; with permission.
employee must believe in the zero-tolerance policy and act accordingly. Because violence has become quite commonplace, every employee, including the critical care nurse, should be prepared, however, to respond to a violent act within their setting. Preventive strategies alone are not sufficient; a crisis response plan is also necessary.
Everyone should expect violence to occur within their workplace. Some people believe that hospitals and businesses should develop universal precautions for violence, proposing that violence should be expected and prepared for in any setting. Despite the heightened awareness for violence prevention and a clearly articulated and rehearsed violence prevention program, violence may still occur. Thus, it is important that employees be prepared to act in response to violence so that the negative outcomes of violence can be minimized. There are four basic intervention strategies that can be used to act in response to violence. These strategies include • De-escalating aggressive behaviors • Self-protection techniques • Protective equipment and alarm systems • Critical incident debriefing and follow-up Without question, the best weapon against violence is good verbal diffusion skills. Many violence prevention programs focus on establishing helpful communication skills with the perpetrator of violence. Methcxls of communication that have been found to be helpful in potentially violent situations include reflecting, clarifying, sununarizing, informing, and focusing. Useful straightfotward statements, such as "you look angry," also helps to focus on the feelings of the person. It is clear that this is the moment of truth, and expertise in interpersonal communication is paramount to a successful outcome. Most hospitals have developed threat assessment or violence prevention teams that are available to assist in aggressive or violent situations. Employees of health care institutions should be aware of their availability and use them to their fullest. Nurses and physicians may also lack expertise in therapeutic communication when working with aggressive or violent individuals; using these consultants is the wisest act possible. "Too often, physicians (and nurses) assume they have the expertise and skill necessary to handle these matters themselves. Difficulties arise when
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the physician (or nurse) lacks experience, or ignores or denies the potential seriousness of a patient threat or act of violence." 10 Deescalation skills are not innate; nor are they routinely taught in many medical or nursing schools. It should not be assumed that a physician or nurse is the most optimally skilled individual to cope with a potentially violent situation (Appendix). Yet, de-escalation skills remain the most helpful action during an act of aggression or violence. If verbal diffusion skills are insufficient to thwart violent behaviors, employees should initiate self-protection techniques. These activities are aimed at protecting oneself and others in the environment from great harm. First and foremost, activate your emergency system and report your name, location, and the "who, what, where and when" of the situation. It may be advisable to have someone other than yourself activate your emergency system; a key phrase or password may be helpful to relay your need for assistance without escalating the disgruntled individual. Direct the adversaries to leave the scene of a confrontation, but do not try physically to force a person to leave. Escape, hide if not already seen, or cover up if injury is likely and make every possible effort to get others out of the immediate area while positioning yourself, if possible, so that an exit route is readily accessible. Never attempt to disarm or accept a weapon from the person in question. Never challenge, try to bargain with a threatening individual, or make promises you cannot keep. If a weapon is involved, calmly ask the person to put it in a neutral location while you continue to talk with him or her. Do not argue, threaten, or block their exit. Protective equipment and alarm systems may also be used in violent situations. Seclusion rooms, bullet-proof enclosures, and other equipment may be used if necessary. Metal detectors may be required in some settings. Developing and using an appropriate alarm system (a password or key phrase) or a panic button, such as those used in convenience stores, may be necessary. Suiveillance cameras can be used and most hospitals have them in place. It is important not to become
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overly confident in the security that surveillance cameras provide, because having the cameras does not ensure that someone is watching them at all times. Last and perhaps most important is the critical incident debriefing or follow-through of the situation. To regain the trust and security of employees in a setting that has experienced workplace violence, it is important to demonstrate sensitivity to the trauma that has occurred and steps aimed at preventing further violent acts. It is important that the organization develop, announce, and implement a plan that takes employees' welfare seriously; establish who will conduct the investigation of this attack and who will be involved; and refer the individual to a staff assistance program if emotional, mental, or psychiatric conditions are suspected. It is also important to make arrangements to secure the building (rekey office doors, retrieve an employee's keys or limit computer access, post photos of persons not permitted to return to work, and alert employees of the perpetrator's restrictions) as well as to provide reassurance to individuals, families, and co-workers.
Workplace Violence and Health Professionals
Stress and violence in the workplace is not a new phenomenon. As health care professionals, however, we have been socialized to believe that the inability to cope with a problem is a taboo subject. Those individuals who are unable to cope effectively are viewed defective, weak, or in need of assistance. Yet any person has the potential for being overwhelmed with stress. Critical care practitioners, including critical care nurses, excel at always being in control and some suggest that critical care practitioners try to control life and death. Critical care nurses are particularly prone to the belief that the inability to cope is an individual weakness. But because of this belief, critical care nurses are at great risk for devaluing or missing cues that someone is overwhelmed and coping poorly. By not facing up to the problems of stress (and critical care
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units are truly stressful envirorunents), greater problems may result. Hospitals, clinics, and other health care systems need to embrace a culture that values the well-being (both physical and emotional) of their patients, visitors, and employees. They need to create frameworks for effective threat assessment and crisis response plans. They need to open up areas of communica-
tion and to link resources to provide violence education. Health care workers need to do a better job of making sure that they increase communication of what behaviors they see around the patient as he or she is coming through the door. By giving information to each other about potentially violent situations, we empower ourselves to prevent violent behavior.
SUMMARY
Workplace violence is increasing, but through education, prevention, and managing escalating crlses, critical care nurses can help to minimize the negative consequences of violence. Critical care nurses are particularly prone to acts of aggression and acts of violence due to the stressful environment for them, their families, and their patients. Developing violence prevention skills and interpersonal communication skills, not always highly valued in a critical care environmei:lt, are important steps in deterring workplace violence. Although not all incidents of workplace violence can be prevented, recognizing the individual at risk for violence and intervening on the behalf of all involved is a responsibility of every employee including the critical care nurse.
REFERENCES 1. Brown SM: The impact of violence on physician practice. Forum http://222.rmf.org:80/w3451.hunl., 1995, pp 1-3 2. Federal Protective Service: What you should know about coping with threats and violence in the federal workplace. http://www.gsa.gov/pbs.fps/fpsl.hunl 1996, pp 1-6 3. Fein RA, Vossekuil B, Holden GA: 'Threat assessment: An approach to prevent targeted violence. http:// www.ncjrs.org/txfiles/threat.txt, 1995, pp 1-11 4. Goodman RA, Jenkins EL, Mercy JA: Workplacerelated homicide among health care workers in the United States, 1980 through 1990. JAMA 272:16861688, 1994 5. Guardian Security Services: Violence in the workplace: A white paper. http://www.stayout.com/ violence/html, 1995, pp 1-5 6. Kenley J, Rizzo J: Managing Violence in the Workplace: A Training Manual. Ann Arbor, Ml, University of Michigan Health System, 1994 7. Laurent A: Short fuse. http://www.govexec.com:80/ features/1296st.html, 1996, pp 1-9 8. National Crisis Prevention Institute: Good verbal diffusion skills can be your best weapon. http://
www.execpc.com:80/-cpVcoweb.hanl., 1995, pp 1-2 9. OSHA 3148: Guidelines for preventing workplace violence for health care and social service workers. http://www.osha.gov/oshpubslwodcplace, 1996, pp 111
9a. Richmond T. Violence lnleroentionsforPatients, Providers, and Public Po/tcy [video conference). New Orleans, LA: American Association of Critical Care Nurses; 1995 10. Satore Township: Violence in the workplace today. http://www.crl.com/-mikekeB/v6.hunl., 1996, pp 1-4 11. Schouten R: When patients threaten. Forum http:// www.rmf.org:80/w3452.html., 1995, pp 1-4 12. Taylor RW: The Rockem-Sockem workplace. http:// venable.com/wlu/rockem.hunl., 1996, pp 1-4 13. Timm HW, Chandler CJ: Combating workplace violence. http://orpheus.amdahl.com/ext/iacp/pskl. toc.hanl., 1996, pp 1-9 14. US Department of Labor: Guidelines for preventing workplace violence for health care and social service workers. Occup Health Saf 3148:1-30, 1996 15. Weiss}: Violence at work: Workplace dangerous for women. http://tradewave.com/galaxy/community/ safetyI assault-prevention/ apin/workwomen. hunl., 1996, p 1 Address reprint requests to Michael L. Williams, MSN, RN, CCRN 211 East Shawnee Street Tecumseh, Ml 49286
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APPENDIX A family received information from the patient in the adjacent room that their mother had been verbally if not physically abused by the nurse on the night shift. They were very concerned and expressed their concern to the day-shift nurse, who agreed to refer their concern to the nurse manager. The attending physician was notified and spoke with the family as well. The response of the physician was simply, ''you have to trust me. I assure you that nothing like that has ever happened in this unit. I work with these nurses all of the time and I can vouch for them." When the family requested to spend the night at the bedside, the attending physician simply responded, "that is against unit policy," and "you can't do that." The family members continued to become agitated and repeatedly stated that, given the information they had at hand, they were concerned for their mother's physical safety. The attending physician responded, "if you don't trust me, then you can transfer her to another facility." At this point, the clinical nurse specialist (CNS) was requested by the nursing staff to intervene. The family was invited into the conference room and asked to share their concerns. After listening to their concerns and restating their issues about the potential safety concern, they were assured that these allegations would be taken seriously and would be investigated fully. They were also assured that the nurse in question would not be permitted to care for their mother. Their anger at the manner in which the physician had interacted with them was verified.
The nurse manager and the CNS met with the physician to gather further information about the situation. The visiting policy was clarified; restricting families from staying the night in the ICU was not a part of the policy. The physician, nurse manager, and CNS agreed to meet with the family once again to help reassure the family. The physician reiterated his perspective that, "you must trust me," and "something like this wouldn't happen here." When challenged by the patient's daughter, the physician became verbally loud, arguing with her and again stating, "you can always transfer her somewhere elseI knew you were going to be a problem when I met you in my office before the surgery." At that point, the CNS intervened, first to stop the physician from escalating the family further and second to clarify each of their perspectives. The physician in fact felt it was important for the family to trust him, but rather than owning up to this need (his personal need to be trusted), he placed the onus on them. Second, it was agreed that none present could ever know what really occurred during the night before because none of them were present. It was also agreed that this was a serious allegation that would be fully investigated. Last, it was agreed that it was important to the family to ensure their mother's safety and allay their fears that they would be allowed to stay the night in the ICU or in the ICU waiting room, and make unannounced visits through the night.