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Washington Watch|Health & Safety|Workplace Rights

Issues Update

American Journal of Nursing - November, 2000 - Volume 100, Issue 11

Violence in the Health Care Workplace
Even after a decade of awareness, prevention standards remain voluntary; it’s time to secure on-the-job safety

By Karen Worthington, RN

On the morning of April 15, 1990, San Diego nurse Debbie Burke and a paramedic student were shot and killed by a disgruntled family member who came to the emergency department with a loaded weapon. This incident brought to light the very real threat of violence that nurses face in their daily lives. Subsequent surveys by state nurses associations, specialty organizations, and labor unions demonstrated that violence in the health care workplace was widespread and not just limited to the emergency department.

As a result of this awareness, the health care community launched several initiatives; the work really took off in 1993. In that year, legislation was passed in California that provided severe punishment for acts of violence against health care workers and required employers to provide training in prevention. The American Academy of Nurses hosted a national conference on violence to identify research priorities and make policy recommendations. And a coalition of health care worker labor unions was formed to bring the problem of violence to the attention of the Occupational Safety and Health Administration (OSHA) and lobby for a standard to prevent violence in the workplace.

Since then, progress has been made on documenting and characterizing the hazard of violence and framing an approach to prevention. Unfortunately, OSHA has yet to release a mandatory standard, choosing instead to publish voluntary guidelines. Furthermore, only a few states and municipalities have introduced violence legislation like that passed in California. So 10 years after Debbie Burke’s death, nurses’ safety remains dependent on whether employers choose to implement prevention programs. Therefore, strong advocacy by nurses and nursing organizations is still needed to ensure the safety of health care workers, patients, and visitors.

THE HIGH COST OF WORKPLACE VIOLENCE

In 1996 a special report by the Bureau of Justice Statistics, Workplace Violence, 1992–96, noted that more than 160,000 workers in medical occupations, including an estimated 70,000 nurses, were victimized in each of those years. The American Hospital Association (AHA) recognizes the problem and its costs to employers, patients, and staff. In the 1996 AHA publication Creating a Secure Workplace: Effective Policies and Practices in Health Care (see Resources, page 70), Massachusetts Nurses Association member Marilyn Lewis Lanza, DNSc, RN, a nurse researcher, cited conservative estimates of the direct costs of physical assaults on health care workers. The average cost per injured worker for medical treatment and lost time alone was $5,719. And it can be much worse: severe, disabling injuries from on-site violence have required more than $100,000. Not included in these estimates were less severe injuries, injuries to patients or property, and the long-term physical and psychological costs of trauma.

In a series of studies published in the journal Behavioral Medicine in 1997, researchers examined the impact of violence on health and documented strong links between victimization and subsequent physical and mental health problems. Physical assault is associated with posttraumatic stress disorder, impaired immune and endocrine function, and increased substance abuse, all of which compromise long-term health and increase demands on the health care system.

Media and industry attention has focused on health care worker fatalities and acts of violence among workers, but while these are clearly lamentable, they account for a very small percentage of health care worker injury overall. In a speech at the National Student Nurses Association Convention in April, Jane Lipscomb pointed out that the vast majority of violent incidents among health care workers are nonfatal assaults, nearly half of which are perpetrated by patients.

A NEW FRAMEWORK FOR PREVENTION

In the last five years, violence in the workplace has come to be viewed as comparable to other occupational hazards, which are amenable to control measures routinely implemented by health and safety professionals worldwide. The aim of such measures is first to try to eliminate a hazard, and then, if necessary, to implement work practice controls or use personal protection equipment.

This occupational hazard approach looks at violence in the context of the total environment, as a “systems problem,” and seeks “systems fixes” to address prevention. Thus, it is an attempt to eliminate hazards through preventative measures, rather than relying on individual responses or behavior. This approach also shifts the focus away from both a “blame the victim” outlook and the profiling of patients as potential perpetrators. In fact, studies show that predicting violence in patients is very difficult, even when using thorough and validated nursing assessments.

THE OSHA GUIDELINES

Although several health care oversight agencies are responsible for patient safety and security, OSHA is the only regulatory agency overseeing the safety of health care workers. So in 1998, under pressure from health care worker unions and organizations (including the ANA), OSHA published its voluntary guidelines, which focus on four main components of prevention: management commitment and employee involvement, worksite analysis, hazard prevention and control, and health and safety training. They also include a workplace violence checklist, policies for assisting assaulted employees, an incident report form, and survey questions on violence.

Management commitment is particularly important, as evidenced by a 1999 study in Epidemiology. ¹   The report found that nurses who believed their administrators accepted on-the-job assault as an expected risk were eight times more likely to become victims of workplace violence.

The ANA supports OSHA’s guidelines for addressing violence in health care facilities and will continue to push for the establishment of these recommendations as mandatory requirements. In the meantime, the passage of state legislation may be an effective way to both mandate compliance and increase the penalty for assaulting a health care worker.

Reference

1. Lee SS, et al. Work-related assault injuries among nurses. Epidemiology 1999;10(6):685-91.

What you can do

• Make sure your facility’s safety committee tracks all assaults on patients, employees, and visitors.
• Make sure the 1998 OSHA violence prevention guidelines are being followed in your facility.
• Encourage fellow employees to report threats as well as injuries.
• Insist that medical treatment and support services be available.
• Include violence prevention provisions in contracts negotiated by worker unions.
• If you are interviewing for a job, make the existence of a violence prevention program a criterion for accepting the position.