Workplace Violence and Incivility

Nurses working in hospitals and other healthcare facilities are at disproportionally high risk for physical violence because of the very nature of their job. We screen patients and their visitors to the best of our ability, but we never know who will walk through the door and in what mental status. To maintain personal safety and an environment free from the potential of physical violence, nurses must be alert to signs of trouble. Not all healthcare workplace violence is of a physical nature or from patients or their families; like any other business, it is subject to horizontal violence and interdisciplinary incivility. Horizontal violence comes in the form of intimidating or derisive behavior between and among staff, managers, or physicians; it interferes with optimal job performance and has negative effects on the delivery of high-quality patient care. Research suggests that workplace violence/incivility can be prevented if people are aware of warning signs and have training on how to effectively deal with potentially violent situations. No organization can completely prevent or eliminate workplace violence, but with proper planning and effective programs, the chances of such violent occurrences can be dramatically reduced.

Objectives

• Categorize the types of violence/incivility that may occur in the workplace.

• Analyze risk factors for potential violence or disruption.

• Describe guidelines for preventing workplace violence and incivility.

• Evaluate your organization’s plan for preventing workplace violence and incivility.

• Evaluate interventions that help prevent horizontal violence and incivility.

interpersonal conflict

lateral aggression

toxic workplace

The Challenge

Lori Jeffries RN University Medical Center Brackenridge, Austin, Texas

I had recently come to work in the emergency department (ED) from a general medical-surgical unit in a different hospital. I had been working in the ED only a few months when the incident occurred. My patient was an older man with mental illness who had not been taking his medication. He appeared to have been living on the streets and presented to the ED confused and mumbling. He did not have a shirt, and he was having difficulty keeping his pants on because the zipper was broken. Our ED keeps donated clean clothing for just such occasions. The clothes were in a long narrow closet where we also kept a gurney used to transport expired patients. You had to squeeze by the gurney to get to where the clothes were. I wanted to make my patient more comfortable by getting him some clean clothes to wear. At the time, I did not think that he was the type of person who might be dangerous. I had him come with me to the closet to make sure the items I picked would fit him because he was tall and solidly built. I went into the closet first, with him following a few feet behind me. I picked up a pair of pants and turned around to hold them up to see if they were about the right size. That is when he backed up and closed the door. I knew then I was in trouble.

What do you think you would do if you were this nurse?

Introduction

Workplace violence and incivility in health care have emerged as an important safety issue over the past decade. It is seen on a continuum from threats or intimidation to its most extreme form, homicide. Violence, whether from persons outside or within an organization, has been shown to have negative effects including increased job stress, reduced productive work time, decreased morale, increased staff turnover, and loss of trust in the organization and its management. The purpose of this chapter is to increase awareness of the risk factors for violence and incivility in healthcare facilities and to provide strategies for decreasing or preventing those events in the workplace.

Defining Workplace Violence/Incivility

As part of the Centers for Disease Control and Prevention (CDC), the National Institute for Occupational Safety and Health (NIOSH) conducts research and makes recommendations to prevent work-related illness and injury. NIOSH works with industry and labor organizations to understand and improve worker safety and health. NIOSH (2002) defines workplace violence as “violent acts (including physical assaults and threats of assaults) directed toward persons at work or on duty.” The definition of violence includes overt and covert behaviors ranging from offensive or threatening language to homicide. In recent years, additional descriptions of other forms of workplace violence have been added. Horizontal violence or lateral aggression has been used to describe aggressive and destructive behavior of co-workers against each other. Other terms associated with this type of violence include bullying and interpersonal conflict. These behaviors exist in what has been termed toxic workplaces. Incivility includes a wide range of behaviors from ignoring, to rolling one’s eyes, to yelling, and eventually to personal attacks, both physical and psychological. Both types of workplace violence are addressed in this chapter and are referred to as violence.

Scope of the Problem

The true scope of workplace violence in health care is difficult to determine. The main source of data for workplace violence and injuries is the Bureau of Labor Statistics (BLS). Fatal and nonfatal occupational injury statistics are collected by the BLS in two major categories: goods-producing and service-providing industries. In a 2006 BLS report of service-providing organizations, healthcare and social assistance organizations had the highest percentage of reported nonfatal injuries (Figure 25-1).

FIGURE 25-1 Distribution of nonfatal occupational injuries by service-providing private industry sector, 2006.

Because the reporting category includes both healthcare and social assistance organizations, accurate data for health care alone are hard to determine. In another BLS summary report released in 2007 (Figure 25-2), more specific analysis indicated employees working in general medical and surgical hospitals had the highest number of nonfatal occupational injuries in private-sector industries. Ambulatory health services and nursing care facilities appeared fourth and fifth in frequencies. When combined, the disproportional incidence in these three healthcare settings is cause for concern.

FIGURE 25-2 Industries with at least 100,000 nonfatal occupational injuries and illnesses, private industry, 2007.

In addition, 114 fatal injuries were reported in preliminary BLS data for health care in 2007. Although this number is a concern, the incidence of fatal injuries is low when compared with the combined number of fatalities or for other types of industries. There are concerns that the true rate is much higher because many incidents are not reported, especially when violence does not result in a physical injury or is verbal in nature such as intimidation or bullying. Underreporting in health care is thought to be related to a perception within nursing that assaults with or without injuries are “part of the job.” One survey of nurses in Minnesota reported that the annual rate of physical and non-physical assaults on nurses per 100 respondents was 13.2 (Nachreiner, Gerberich, Ryan, & McGovern, 2007). According to Hader (2008) in a survey conducted by Nursing Management, 80% of the 1377 nurse respondents from the United States and 17 other countries reported they had experienced some form of violence within the work setting (Box 25-1). Verbal rather than physical forms of violence were reported most often. According to the survey, the perpetrator was a patient 53.2% of the time, with nurse colleagues a close second at 51.9% of the time. Next in the ranking were physicians (49%), visitors (47%), and other healthcare workers (37.7%). Nurses observed their colleagues being the primary target of this violence (79.7%) and had personally been the target (56.1%). Many earlier studies with similar findings demonstrate the need to examine the causes of workplace violence and develop programs and strategies to improve personal safety in the work environment. In particular, attention needs to be paid to the causes and remedies for lateral violence issues.

BOX 25-1

Types of Violence

Intimidation	75.9%
Angry outbursts	71.9%
Hypersensitivity to criticism	71.5%
Belligerence	66.9%
Threatening/disruptive behavior	64.6%
Bullying	59.8%
Harassment	51.6%
Threats of physical violence	38.9%
Obsession with a supervisor	28.5%
Ominous or specific threats	27.9%
Physical violence	25.8%
Intentional property damage	17.0%
Preoccupation with recently publicized violent events	8.3%
Carrying or storing weapons	7.5%
Preoccupation with violent themes	5.9%
Recent acquisition of or fascination with weapons	5.6%

From Hader, R. (2008). Workplace violence survey 2008. Nursing Management, 39(7), 13-19.

Ensuring a Safe Workplace

Although no national legislation or federal regulations specifically address the prevention of workplace violence, the Occupational Safety & Health Administration (OSHA) has published voluntary guidelines for workers in healthcare and several other high-risk professions. Although employers are not legally obligated to follow these guidelines, the Occupational Safety and Health Act (OSH Act) (1970) mandates that, in addition to complying with hazard-specific standards, all employers have a general duty to provide their employees with a workplace free from recognized hazards likely to cause death or serious physical harm. An organization can be cited if its leaders fail to address such hazards. Because healthcare workers are at increased risk, OSHA (2004) developed Guidelines for Preventing Workplace Violence for Health Care and Social Service Workers to assist healthcare organizations in developing violence prevention plans. Several states are also enacting or developing laws, standards, or recommendations that address healthcare workplace security and safety. Many of these laws have been created with strong support from state-based nursing organizations with support from the American Nurses Association (ANA) and other professional healthcare organizations (ANA, 2009). A few states have passed laws that enhance criminal penalties on crimes committed against licensed or certified health professionals. Many other states have or are working on legislation requiring healthcare organizations to have a workplace violence prevention plan (Figure 25-3).

FIGURE 25-3 The American Nurse Association’s Nationwide State Legislative Agenda for workplace violence, June 2009.

The Joint Commission (TJC) (2008) has strengthened requirements in their Leadership standards for dealing with disruptive behavior. Citing studies that suggest intimidating and disruptive behaviors contribute to poor patient satisfaction and preventable adverse outcomes, the standards calls for codes of conduct and processes for managing such behaviors. These standards became effective in January 2009.

The Cost of Workplace Violence

Our knowledge of the scale of workplace violence remains incomplete because no consistent system of data collection exists. Data regarding the less severe forms of workplace violence are particularly sparse. Even less clear is the financial toll workplace aggression exacts on businesses. A Workplace Violence Research Institute (1995) study estimated the aggregate cost of workplace violence to U.S. employers to be more than $36 billion as a result of expenses associated with lost business and productivity, litigation, medical care, psychiatric care, higher insurance rates, increased security measures, negative publicity, and loss of employees. Pearson and Porath (2009) suggest that estimates of cost should consider how many times people report they are sick when they are really avoiding bad behavior and decreases in productivity because employees no longer feel comfortable in the environment. These costs mount rapidly.

Researchers (Hartley, Biddle, & Jenkins, 2005) from the National Institute for Occupational Safety and Health (NIOSH) have attempted to determine the cost of the most extreme workplace violence using a model that calculates direct and indirect costs of workplace fatalities, including medical expenses and lost earnings. NIOSH estimated the average mean cost of a workplace homicide incident, from 1992 to 2001, to be $800,000. The total cost of workplace homicides during this same period totaled nearly $6.5 billion. Studies have yet to capture the full cost of workplace violence in its many forms. More measurement is also needed to assess the cost and effectiveness of known intervention strategies.

Making a Difference

So what is the nurse in a leader, manager, or follower role to do given the serious and complex issue of violence in the workplace? Making a difference includes promotion of an organizational culture of safety, developing and implementing a safety strategy, providing training programs, predicting problems, and using technology to reduce the incidence of violence. In addition, personal strategies to prevent being victimized by violence in any setting are critical.

Prevention Strategies

The old adage “an ounce of prevention is worth a pound of cure” is particularly relevant when dealing with workplace violence. Preventing even one act of violence can save money and time and diminish the possible negative psychological impact of such an event. The costs from lost work time and wages, reduced productivity, medical costs, workers’ compensation payments, and legal and security expenses may be difficult to estimate but are clearly excessive when compared with the cost of prevention. Other future costs of workplace violence include increased staff turnover rates. Loss of the organizational investment required to train qualified staff and departure of experienced existing staff can increase operating expenses and reduce the quality of care. By taking a proactive approach that includes preventing violence, organizations can also avoid being victimized. To address the issue of violence, it is necessary to have a broad understanding of types of violence that may be encountered and the signs that portend a potentially violent situation. In short, prevention is the right thing to do for people and for the organization.

Types of Violence

Since 1990, the University of Iowa Injury Prevention Research Center (IPRC) has been one of 11 injury “Centers of Excellence” funded by the National Center for Injury Prevention and Control, a branch of the CDC. Workplace violence has been one of their research focus areas (2001). The University collects and uses epidemiologic data on groups at high risk in order to develop prevention strategies and training to control and prevent injuries. In their investigations, they categorize workplace violence into four types (Box 25-2).

BOX 25-2

Categories of Workplace Violence

Criminal Intent (Type I): The perpetrator has no legitimate relationship to the business or its employees and is usually committing a crime in conjunction with the violence. These crimes can include robbery, shoplifting, and trespassing. The vast majority of workplace homicides (85%) fall into this category.

Customer/Client (Type II): The perpetrator has a legitimate relationship with the business and becomes violent while being served by the business. This category includes customers, clients, patients, students, inmates, and any other group for which the business provides services. A large proportion of customer/client incidents are believed to occur in the healthcare industry, in settings such as nursing homes or psychiatric facilities; the victims are often patient caregivers. Police officers, prison staff, flight attendants, and teachers are some other examples of workers who may be exposed to this kind of workplace violence.

Worker-on-Worker (Type III): The perpetrator is an employee or past employee of the business who attacks or threatens another employee(s) or past employee(s) in the workplace. Worker-on-worker fatalities account for approximately 7% of all workplace violence homicides.

Personal Relationship (Type IV): The perpetrator usually does not have a relationship with the business but has a personal relationship with the intended victim. This category includes victims of domestic violence assaulted or threatened while at work.

From Iowa Injury Prevention Research Center. (February 2001). Workplace violence: A report to the nation. University of Iowa—Iowa City. Retrieved October 28, 2009, from www.public-health.uiowa.edu/iprc/resources/workplace-violence-report.pdf.

These categories can be very helpful in the design of strategies to prevent workplace violence, because each type of violence requires a different approach for prevention, acknowledging the fact that some workplaces may be at higher risk for certain types of violence. Understanding the types of violence allows leaders to conduct a more focused risk assessment based on what types of crimes may occur.

Risk Assessment

Although anyone working in health care is at risk for becoming a victim of violence, those with direct patient contact are at higher risk. NIOSH (2002) reports that healthcare workers in hospitals, specifically those in the emergency department, are at particular risk. Violence is also a frequent occurrence in psychiatric and geriatric settings. Unlike in other settings, hospital violence differs in that it is usually the result of patients or their family members feeling frustration or anger. This is usually related to feelings of vulnerability, stress, and loss of control that accompany illness. Many factors have been identified that can increase the risk for violence erupting in healthcare facilities. Risk factors identified in OSHA’s Guidelines (2004) are listed in Box 25-3.

BOX 25-3

Risk Factors for Violence in Healthcare Facilities

• Working when understaffed, especially during visiting hours and meal times

• Transporting patients between areas in a facility

• Long waits for patient care

• Overcrowded, uncomfortable waiting areas

• Working alone or in an area isolated from other staff

• Solo work with patients in areas with no back-up or way to get assistance, such as communication devices or alarm systems

• Poor environmental design

• Inadequate security

• Lack of staff training in handling potentially violent situations

• Lack of policies for preventing and managing crises with potentially violent individuals

• Unrestricted movement of patients or visitors

• Poorly lit corridors, rooms, parking lots, or other areas

• Prevalence of handguns or other weapons among patients, their families, or friends

• Increasing presence of gang members, drug or alcohol abusers, trauma patients, or distraught family members

• Use of hospitals or healthcare facilities for holding criminals, violent individuals, and the acutely mentally disturbed

• Serving chronically mentally ill patients being released without adequate resources for follow-up care

• Availability of money or drugs within the facility

Adapted from Occupational Safety & Health Administration (OSHA). (2004). Guidelines for preventing workplace violence for health care and social service workers. Retrieved October 28, 2009, from www.osha.gov/Publications/osha3148.pdf.

Other risk factors for violence include the location of the facility, its size, and the type of care provided. Facilities located in inner-city areas that serve a wide variety of the disadvantaged, especially those with mental illness or a history of violent behavior or those who are under the influence of drugs or alcohol, are at increased risk for violence to occur. Review of reports of violent incidents reveals they often take place during times of high activity and interaction with patients, such as at meal times and during visiting hours and patient transportation. Assaults may occur when service is denied, when a patient is involuntarily admitted, or when a healthcare worker attempts to set limits on eating, drinking, or use of tobacco or alcohol.

BOX 25-4

Workplace Violence Program Checklists

OSHA and ANA have provided comprehensive checklist documents that can assist leaders and managers in conducting an organizational workplace violence assessment. The checklist titles are provided here. The checklists provide detailed step-by-step instructions to conduct an in-depth assessment and establish a monitoring program. To see the complete document, go to www.osha.gov (OSHA Publication No. 3148-01R 2004).

Checklist 1: Organizational Assessment Questions Regarding Management Commitment and Employee Involvement

Checklist 2: Analyze Workplace Violence Records

Checklist 3: Identifying Environmental Risk Factors for Violence

Checklist 4: Assessing the Influence of Day-to-Day Work Practices on Occurrences of Violence

Checklist 5: Post-Incident Response

Checklist 6: Assessing Employee and Supervisor Training

Checklist 7: Recordkeeping and Evaluation

Adapted from American Nurses Association: Promoting Safe Work Environments for Nurses, 2002. (From Occupational Safety and Health Administration (OSHA). (2004). Guidelines for preventing workplace violence for health care and social service workers (OSHA Publication No. 3148-01R). Washington, DC: U.S. Department of Labor. [www.osha.gov])

When looking at possible threats or hazards, those from within an organization also must be considered. Determining if current employees pose a danger in the workplace is a critical factor that is often overlooked. In addition to personal and psychological factors, behaviors can be observed in employees that may be related to violence or aggression in the workplace (Paludi, Nydegger, & Paludi, 2006). The most obvious of these is a previous history of aggression and substance abuse. Screening potential employees through drug testing, background checks, and references can help reduce these risks. Paludi et al. (2006) also advise of warning signs that can alert employers of problems with current employees that warrant intervention to prevent a violent incident.

Firing Right

Organizational conditions or outcomes may magnify the potential for violence to erupt. This includes prolonged high levels of stress or factors that create what is known as a toxic workplace environment. Rapid change, layoffs, changes in schedules and workloads, or wage freezes could have this effect. The employment situation with the highest potential to create this kind of stress is the firing or layoff process. Most organizations have specific protocols that deal with the process of terminating employees, because firing is cause for strong emotions that can increase the potential for violence. As a manager, you may be responsible for staff terminations. The goal always is to conduct the process in the most professional manner possible, although organizational rules may specify a detailed procedure. A few tips on how to prepare for this potentially problematic situation are provided in Box 25-5.

BOX 25-5

Firing Right

Firings should be planned with forethought for any potential problems. Steps should be taken to avoid potential violence during employee separation. A key step is protecting the employee’s dignity and avoiding humiliation. The reasons for termination should be clear and leave no room for debate. All details should be arranged, including timing, the room used, and who is present. The room should provide privacy but not contain any objects that could be used as a weapon. The person being terminated should not be blocked from accessing the exit door. Termination notices and severance checks along with any other documentation should be on hand. Arrangements should be made to clean out the person’s desk or locker. There should be no reason for the person to return to the worksite. This saves everyone from embarrassment and any potential scenes. It is important to try to determine how the person will react to make appropriate arrangements. If there is a perceived need, a security officer or off-duty police officer can be called to stand by.

Adapted from Winfeld, L. (2001). Training tough topics. New York: American Management Association.

There is no profile or litmus test to identify whether a current employee might become violent. It is important for employers and employees alike to remain alert to problematic behavior that, in combination, could point to possible violence. Because no one behavior in and of itself suggests a greater potential for violence, behaviors must be looked at in totality. Problem situations, circumstances that may heighten the risk of violence, can involve a particular event or employee or the workplace as a whole.

Exercise 25-1

Assess several clinical settings for workplace violence risks. Can you identify any based on what you have read? What security measures are currently in place? Can any of them be improved? How safe would you feel in the different geographical areas?

Once the risk assessment is completed, the next step is to analyze the data and prioritize the problems that need to be addressed. Priorities can be established by asking a few basic questions: What are the risks? Who might be harmed and how? What is the level of risk? What measures need to be taken to reduce or eliminate risk? Do we need to implement changes now or later? Once the priorities are set, the business of designing or improving prevention programs can begin. (See the “Developing a Safety Plan” section on p. 508.)

Horizontal Violence: The Threat from Within

Horizontal or lateral violence describes a wide variety of behaviors, from verbal abuse to physical aggression between co-workers. This term, though commonly used, may be limiting because it suggests the violence is perpetrated between those at the same level of authority. It may be better termed relational aggression (Dellasega, 2009), which can occur between people at different levels. This includes bullying behavior and intimidation. Horizontal violence or bullying is used in this section because these are terms common in the literature. Horizontal violence and its effects have been reported in nursing literature for more than 20 years. In a review of five research studies on horizontal violence, researchers (Woelfle & McCaffrey, 2007) found that horizontal violence is experienced by not only student nurses but also the novice and veteran nurses. Many of the research reports found infighting and a general lack of support of nurses for each other to be common occurrences. The studies also indicate that new graduates were likely to experience horizontal violence, which resulted in high absentee rates and thoughts of leaving nursing after their first year. This caused the researchers to ask this question: How can nurses treat patients kindly and give them the respect they need when they treat each other so poorly? In light of the looming nursing shortage, these consistent findings among nurses were cause for concern.

Many theories exist as to why horizontal violence exists in nursing, ranging from nursing’s traditional hierarchical structure, to oppression of nursing as a profession, to feminism (Farrell, 2001). However, it is also noted that workplace aggression is common in other professions and is most likely the result of a complex myriad of individual, social, and organizational characteristics (Farrell, 2001, Hutchinson, Vickers, Jackson, & Wilkes, 2006). Regardless of the reasons why it happens, the concerns are that impaired intrapersonal relationships between nurses at work can cause errors, accidents, and poor work performance (Farrell, 1997) and may play a significant role in attrition (Johnson, 2009). In a survey on workplace intimidation published by the Institute for Safe Medication Practices (2003), almost half of the 2095 respondents recalled being verbally abused when questioning or clarifying medication prescriptions. This intimidation played a role in not questioning an order as a way of not directly confronting the prescriber. The results of the survey had professional healthcare and nursing organizations issue calls to action to address all types of workplace violence in the interest of promoting a safe and respectful work environment that promotes the delivery of high-quality care instead of threatening it. Shortly after the publication of the release of the Institute’s report, the International Council of Nurses (ICN) (2006) published a position statement on healthcare workplace violence. The ICN also asserted the following:

Violence in the workplace threatens the delivery of effective patient services and, therefore, patient safety. If quality care is to be provided, nursing personnel must be ensured a safe work environment and respectful treatment. Excessive workloads, unsafe working conditions, and inadequate support can be considered forms of violence and incompatible with good practice.

In 2008, the Center for American Nurses published a position paper stating there is no place in a professional practice environment for lateral violence and bullying among nurses or between healthcare professionals. These disruptive behaviors are toxic to the nursing profession and have a negative impact on retention of quality staff. Horizontal violence and bullying should never be considered normally related to socialization in nursing nor be accepted in professional relationships. The statement goes on to assert that all healthcare organizations should implement a zero tolerance policy related to disruptive behavior, including a professional code of conduct and educational and behavioral interventions to assist nurses in addressing disruptive behavior. See the Literature Perspective on p. 506. A number of other state and national nursing organizations also have issued statements regarding the detrimental effect of disruptive behavior on both patients and nurses and have called for solutions to address the problem. TJC (2008) proposed a revision in its standards for disruptive behavior, identifying manifestations of abuse and violence in the workplace and providing avenues for ending this phenomenon. With professional groups calling for change from within nursing and accreditation groups calling on administration to fix problems, we must examine how to implement a change.

Literature Perspective