Workplace Violence in Health Care

Abstract

The paper focuses on the issue of workplace violence and the legislation for managing the problem in healthcare. Workplace violence entails incidences of abuse, distinct threatening, intimidation and assaulting cases to persons, under work-related settings, thus affecting their safety, health or well-being either explicitly and/or implicitly. The legislature of focus is “H.R. 5223: The Health Workplace Violence Prevention Act” introduced and sponsored by California representative Sen. Ro Khanna, among other crucial legislators. The H.R. 5223 requires OSHA in mandating the creation of standards, programs, and workplace violence prevention plans by health facilities. The impact of H.R. 5223 includes minimizing violence in healthcare by ensuring enough staffing, participation, and stipulates investigation and management plans for violence. Of all assault cases, 75% are attributed to workplaces, with attacks towards employees accounting for 93%. Of all professionals, nurses are the most affected, with verbal violence as the highest type of violence. Mental departments record the highest rates. Adverse impacts of violence are distress, injuries, anger and high frustrations, sadness, being over-vigilant, absenteeism, and turnover, all of which impacts on quality of care. Nurses have a role in legislation by policy implementations, reporting violations, and being advocates for H.R. 5223 success.

Workplace Violence in Health Care

Introduction

The provision of quality and efficient healthcare ranks as a major objective of public health. Health policies and legislation serve a vital role in setting out regulations, plans, and actions for the undertaking by the different stakeholders for the realization of specified societal healthcare objectives. On a broader sense, legislation and other health measures all aimed at ensuring health providers are efficient and able to deliver quality care. The provision of the right working environment for nurses, physicians, and other healthcare staff, is vital in contributing to caregiving. Workplace violence in healthcare gets recognized as a key issue, affecting health providers, the administration and subsequently impacting on the quality of care provided to patients and families.

Healthcare Legislature: The Health Care Workplace Violence Prevention Act (H.R. 5223)

The H.R. 5223: Health Care Workplace Violence Prevention Act got introduced as of 8

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of March 2018, and sponsored by Ro Khanna (U.S. Representative for California). According to Govtrack (2018), some of the other co-sponsors include Brady Robert, Chu Judy, Gabbard Tulsi, Jackson Lee, Sheila Jayapal, Pramila, Lee Barbara, and Moulton Seth among other legislatures. The principal objective of the act is for the directing healthcare employers covered to adopt comprehensive workplaces violence prevention programs/plans fully. The H.R. 5223 Act, finds its application through the improvement of the Occupational Safety and Health Act (OSHA). Notably, as noted by Safety Health (2018), the act is focused on directing the OSHA towards the creation of well-aligned standards which demands that health facilities implement a well-designed facility and unit-based workplace violence prevention plans.

The principal goal of the H.R: 5223 Act (in verbatim) entails: “To direct the Secretary of Labor to issue an occupational safety and health rule that requires covered health care employers to adopt a comprehensive workplace violence prevention plan and for other purposes” (Govtrack (2018). Some of the critical standards and procedures within the Act include:

1. The procedures for the identification and timely evaluation of the environment as well as specific patient risk factors, e.g., weapons, history of substance abuse, etc.
2. Procedures for timely correcting of workplace violence hazards, e.g., no working alone in risk work settings, mandatory security provision, and working communicating devices, etc.
3. Procedures in place for effectively responding to workplace violence emergencies (actual and potential), with the ability to get help from security personnel or agencies.
4. Active participation of employed health workers in the developing, implementation and subsequent review of workplace violence strategies.
5. Among other procedures aligned with the minimization of workplace violence against healthcare employees.

Overview of Workplace Violence in Healthcare

Workplace violence in health care is a major occupational concern that adversely impacts on nurses and other health specialists (Brophy, Keith & Hurley, 2018; Martinez, 2016). Notably, workplace violence entails actions or incidences in which there is the abusing, specific threatening, intimidation as well as cases of assaults (minor or fatal), to a person, under work-related circumstances which challenges their safety, health or well-being either explicitly and/or implicitly (Yang, Stone, Petrini & Morris (2018). The World Health Organization categorization of violence in the workplace comprises of two cases of physical abuse and secondly psychological abuse, which results in the harming the victims physical, mental well-being, spirituality, their morality and their social development when at work (Zhao et al., 2015). Physical violence is more “physical” and involves instances of slapping, pushing, beating, stabbing, kicking, pinching and in other cases shooting or biting (Zhao et al., 2015).

As a health concern, workplace violence is not only a local issue but also an international problem which impacts on nurses and other specialists worldwide. Philips (2016) explains that workplace violence gets underreported in healthcare, is a persistent and ubiquitous health concern, highly tolerated and ignored in healthcare delivery. Of the different settings and units in healthcare facilities, violence is highest in nursing homes, emergency departments and psychiatric units or settings (Martinez, 2016).

Patient aggression, as a form of violence, ranks among the most common type which occurs against nurses in their clinical settings, in the emergency department, at the inpatient psychiatric units and nursing homes (Martinez, 2016). And although violence types vary, physical and verbal assaults top the list as the most common workplace violence types getting faced by nurses shared by Brophy, Keith and Hurley (2018), shares the same ideas by explaining that Healthcare providers also suffer the risks of violence, either physical, sexual, as well as verbal assaults from the specific patients under one’s care in healthcare settings. Hence, in as much as there is focus on management or co-worker related violence, analysis and management of violence attributed to patients (or also their families) are essential in instituting working interventions to deal with the problem. When at risk of patient violence, nurse personnel suffer effects of associated physical, but also the risk of psychological, interpersonal, and even finance impacts (Brophy, Keith & Hurley, 2018).

As a health concern, health workplace violence has adverse implications for the delivery of care and the well-being of the nursing staffs and other care providers. With increased violence, some of the long-term repercussions include higher rates of missed workdays, job dissatisfaction, more burnout as well as declines in staff productivity (Philips, 2016).  Martinez (2016) notes for nurses encountering aggressive cases at the workplace, there is the experiencing of anger, heightened frustration, sad feelings, being over-vigilant, distress disorder, and might abandon work, among other associated impacts. With the continuity of the issues and violence, there are other long-term effects like increased fear in nursing staff, which results in applying response mechanisms like protecting themselves using weapons, e.g., firearms or even knives (Philips, 2016). Thus, with the persistent of workplace violence for nurses, physicians, and other healthcare staff, the injuries linked with continuous violence hence results in more absenteeism at work, all of which impacts on the quality of care.

The evidence that health workplace violence is an issue calls for applying stringent measures in handling the situation by managing the risk factors among other interventions. According to Martinez (2016), some of the significant workplace violence precursors include staff themselves, the working environment, and the patients, which increases the cases of patient-initiated violence. As noted by Martinez (2016), the top staff risk factors for the occurrence of violence included inadequate or zero training of nurses, working alone, poor control of assaultive actions and being understaffed. The common environmental risk factors initiating increased healthcare violence against nurses include inadequate security, delayed patient services, and caring for potentially dangerous patients in health settings (Philips, 2016; Martinez, 2016). Zhao et al. (2015) say having trusted, efficient and just employment environments have the potential of reducing rates of violence against the various practicing nurses. Hence, in as much as hospital management focuses on providing quality care to patients, nursing staff must also be catered for efficiently. Conversely, some patient associated elements and risk factors were gun accessibility as well as substance abuse (Martinez, 2016).

The management of violence in health institutions is essential if one is to receive the best and quality care. In addition to legal measures, different authors provide useful interventions, all of which when applied have the impact of safeguarding nurses and other health employees. Some of the prevention strategies entail increasing staff numbers, enhancing hospital or care settings security, use of personal alarms, and operational changes (zero tolerance to violence policies) within the hospital (Brophy, Keith & Hurley, 2018). Additionally, there is the need for instituting a simplified reporting platform within the health facilities, application of laws from the crime and justice system, training of personnel and flagging of violence issues. Philip (2016) also agrees with the need for reporting violence and redress in healthcare. As nurses and other providers, it is value in recognizing verbal cases of assault as a risk factor for other violence cases. In the situations where there is tolerating of verbal abuses as well as the different minimal level of work battery, the tolerance is a risk factor for the occurrence of other severe types of healthcare violence. Thus, as healthcare administrators, tolerance to the warning signs during the care process must be minimized. It is essential to pinpoint signs of threatening languages and minor signs of patient agitation and after that initiate interventions or control on time. The cases of violence, whether small or significant, to security personnel, higher management, leaders or supervisors increase the chances of preventing violence escalation, as opposed to silence (Martinez, 2016; Philips, 2016).

Nevertheless, the success in handling health workplace violence also depends on the management of some of the key barriers, which hinders or negatively impacts on the whole process. As noted by Brophy, Keith and Hurley (2018), key barriers include underreporting by health staff; poor respect from patients, families and visitors, also poor communication in hospitals. Similarly, there is the threat of reprisal among nurses and other health workers, for the speaking publicly about the violence concerns in hospitals and other health facilities, which leads to continuity of violence, despite its adverse implications on the staff.

Also, Martinez (2016) says that significant barriers contributing to underreporting phenomenon of workplace violence cases entail nurses fearing retaliation from employers and even the incidences of minimal administrative support. There is the notion and sense that as nurses, one is afraid of losing a job when they report as well as the idea that reporting the violence incidents changes nothing in the current state of workplace violence (Martinez, 2016). And as a control measure, it is mandatory that each reported case gets reviewed, with the same concentration and power as any other issue (Philips, 2016).

Health Workplace Violence Statistics and Impact Distribution

The various researchers agree on the occurrence of workplace violence in healthcare settings, with differences in rates all due to distinctive reasons and factors. As noted by Philip (2016), the most prevalent causes of violence in health settings involves one in which perpetrators have a valid and legitimate relationship to the place of receiving care.  Experts categorize this type of abuse as Type II assault and are the most common in healthcare settings. Also, even if the employment industry in the USA and other global nations is diverse, the highest violence instances are attributed to health care providers (Martinez, 2016; Philips, 2016). By the end of 2013, the overall numbers of assaults in the workplace averaged 24,000 per year. Of the 24,000 cases, around 75% get attributed to healthcare facilities.

According to Philips (2016), with results from a 2014 survey, the Type II assault workplace violence gets attributed to 75% of all aggravated cases of assault. Also, of the 75% of the cases, attacks towards employees accounted for 93%. The statistics show that in all cases reported, patients and other stakeholders received only 3% of the reported assaults, which indicates a distribution bias and the bid spread of the problem on health providers. In addition to mild cases of violence, fatal attack gets recognized as another risk issue in healthcare provision. As reported by Philips (2016), 25% of all fatal (deadly) cases get attributed to occurring at the workplace, with 75% associated to other situations, e.g., homes, social places, etc.

There is also a disparity distribution of workplace violence cases in healthcare among the different professionals. Even though hospital settings contain diversified staff, ranging from physicians, the management, nurses and other none-medical teams, nurses are the most victims of violence (Martinez, 2016; Phillips, 2016; Yang et al., 2018). The reason for the high reported instances of nurse violence in healthcare lies in the correlation between rates of assault with the contact time with patients (Philips, 2016). Thus, with nurses having the most contact time during the caregiving process with patients, there is the increase in instances of workplace violence, all initiated by the patients. This makes client-initiated violence as one of the frequent cases being faced by nurses (Martinez, 2016).  Thus, with the determination of the increased rates of violence towards nurses, designing interventions must always focus on all stakeholder, with nurses are essential. Finally, for male nurses or those undertaking duties caring for male adult patients in PICUs, there is an increased risk of WPV (Yang, Stone, Petrini & Morris (2018).

There are disparities in types of violence as noted by Yang, Stone, Petrini & Morris in 2018. Of the various forms of violence in healthcare settings, verbal aggression ranks as the highest concern in healthcare settings. On a global scale, two-thirds of all professional nurses’ experience verbal aggression when on duty. Additionally, the nurses delivering quality care in designated mental health department suffer the highest risk of unwanted violence, either physical or psychological, with an over 50% of nurses reporting incidences of verbal aggression. Moreover, in mental units, reports indicate that a third (33.34%) of all reported cases arose from physical attacks (Yang, Stone, Petrini & Morris (2018). Also, in the study by Yang et al. (2018), the authors indicate the variations in reported cases of violence, as shown in figure 1 below:

Figure 1: Excerpt from Yang et al. (2018) on the incidences of various workplace violence types

Source: Yang et al. (2018).

From the study by Yang et al. (2018), it gets seen that of all the participating persons, the highest incidences of violence included verbal aggression, followed by physical attacks and finally sexual harassments.

The risk factors for workplace violence towards health providers also depict a disparity, with some elements being major in leading to violence. In the study by Yang et al. (2018), the authors identified some of the 3-most factors contributing to the occurrence of workplace violence. The factors range from patient risks, management factors, societal factors and nurse factors, all of which get recognized as leading to the rates of workplace violence in health facilities. Understanding risk factors which act as causal agents is an essential stride managing the cases of violence.

Figure 2: Excerpt from Yang et al. (2018) on Key Factors Associated with Workplace Violence

Source: Yang et al. (2018).

The provision of specialized home care gets noted as another source of violence for health workers, while on duty. Philips (2016) says that when providing services to patients in the home care, there are increased risks to the staff as the home environment of patients is less controlled. Therefore, although nurses are performing their workplace duties, the occurrence of violence is evident. There is a 61% rate of all home health care providers reporting the incidences of workplace violence per year. Some of the issues nurses and other care providers encounter while doing their duty in homes includes the presence of drugs, unwarranted weapons, cases of robbery, and family violence.

Health Outcomes of the “Health Workplace Violence Prevention Act” Implementation

The occurrence of workplace violence in healthcare has various adverse outcomes, which impacts not only nurses but also other professional workers. Some negative consequences include experiences of psychological as well as physical effects. Though the continued impacts, there is an adverse effect on the nurse’s career as violence leads to poor performance, low morale and excess dissatisfaction with work. Through the persistent encountering with instances of physical and verbal aggression at work, nurses tend to experience cases of anger, frustration with the environment, increased hopelessness, and get hyper-vigilant (Martinez, 2016; Zhao et al., 2015). Other impacts resulting from workplace violence includes PTSD (post-traumatic stress disorder), the developing of anxiety or cases of depression, and might also decide to stop being nurses (Martinez, 2016; Philips, 2016; Zhao et al., 2015).

Based on some of the negative impacts evidenced with the persistent occurrence of workplace violence in health centers, the implementation of sufficient evidence-based practice interventions is vital in helping to decrease violence incidents at work (Martinez, 2016; Yang et al., 2018). The implementation of the H.R: 5223 Act has some of the essential health outcomes as explained below:

Minimization of Health Worker Violence

The Health Workplace Violence Prevention Act is critical to the safeguarding of the well-being of nurses and other health providers. Notably, in its procedures and mandates, the H.R. 5223 Act puts much emphasis on the efficient prevention of workplace violence, strong nurse training, and regular participation in the development of workplace violence policies. Thus, through the H.R 5223 Act, it is possible in the minimization of workplace violence incidences, as it mandates the various healthcare facilities in implementing strong standards and policy procedures, all aimed at the ensuring of the well-being of healthcare workers. Through the Act, the benefits not only fall on nurses, and other healthcare employees involved in the delivery of care in healthcare settings. The H.R. Act provides procedures which will lead to positive outcomes of minimized physical violence, in addition to related threats of violence.

Availability of Conducive Working Environments for Nurses

Under the H.R 5223 standards and procedures, the employer or health facility has the role of assessing the workplace environmental risk factors, and subsequently implementing actions to correct the risk factors. The authors Philips (2016), Martinez (2016) and Zhao et al. (2015), agree that environmental risk factors are among the contributing risk factors for the increased rates of violence against health workers. Through the assessments, some of the potential interventions which are useful in minimizing workplace violence include:

• Sufficient affixing of nursing unit furniture to prevent incidences of being used as weapons
• Collecting and removing any unwarranted objects or tools not related to healthcare delivery, which might act as avenues for violence, e.g., poles, walking sticks or trash cans.
• Fixing lighting in units to minimize potential perpetrators from taking advantage of poor lighting and therefore cause harm to the attending nurses.
• Maintenance of sight visibility in nurse units between the nurses and the patient’s beings cared for to prevent harassment behind blind spots.
• The provision of easy accessibility to healthcare facility panic buttons, communication phones, which are useful in calling for assistance and help when under violence.
• Facilities must ensure that health units have at least one security staff.

The implementation of environmental assessment and implementation of working interventions hence has the impacts of overseeing that nurses work in a place that has less probability of supporting violence. As a goal, all healthcare facilities must focus on the provision of a nurse environment that meets the safety standards of nurses (including other health providers).

The Act Ensures Sufficient Staffing and Staff Participation

Staffing is also a critical procedural mandate within the H.R. 5223 Act, as it stipulates the improvement in staffing as a crucial measure in dealing with instances of workplace violence. The Act requires that health frailties undertake an adequate factor assessment which includes the analysis of the workplace staffing patterns and situations of insufficient staffing, which might act as contributing factors to the occurrence of workplace violence. The ACT requires that healthcare facilities ensure that there are sufficient numbers of health care staff, as well as security personnel. Having the right amount of staff and security measures are vital in the management of rates of workplace violence (Martinez, 2016; Philips, 2016). Through the mandate, the H.R. 5223 Act provides the healthcare facilities with the responsibility of timely assessment of the workplace and ensures that loopholes in staffing do not act as the risk conditions for violence.

The Act Stipulates an Investigation and Management Plan for Violence

Likewise, the H.R. 5223 Act gives out procedures for health facilities to develop and implement plans on the systems for application in the investigation of the various violence concerns, brought forward by the employees. By having a well-laid out investigation and solving strategy, the ACT helps in ensuring that nurses and other health care providers are best served and cared for when there is the occurrence of workplace violence. As noted by Martinez (2016), some markers for reporting incidences of violence showed the loss of trust in the system to solve the concerns. Thus, through the mandating of health facilities to have an elaborate plan for managing violence, nurses, physicians, and other staff have a better chance of getting justice.

Role of Nursing in Legislature

The success of healthcare legalizations relies on the support, impact, and roles played by the different stakeholders. And with nurses forming a part of the health care system, taking a role in making changes is essential, and they should take part in the influencing of policy formulation as opposed to only implementation (Arabi, Rafii, Cheraghi & Ghiyasvandian (2014). Despite the different health policies and legal stipulations, nurses must play an active function in developing health policies, which helps in controlling their practice. Health policies and other laws meet their objectives when purposed, well enforced and implemented within the broader community by the most affected members. As care providers, nurses are key stakeholders, whose role is vital in the initial and subsequent process of health policies, like the H.R.: 5223.

The support for the H.R. 5223 is seen by the National Nurses United, which is one of the largest unions for nurses, who openly supported the act introduction through peaceful support protests on Women’s Day (National Nurses United, 2018). According to the Union, the support arises from the fact that as nurses, they face the significant impact of violence, compared to other professional industries. Through the support using placards with inscriptions such as “Nurses Say Stop the Violence: Heal America,” the National Nurses United acts as a benchmark for the success in the implementation and enforcement of the Health Care Workplace Violence Act, a vital tool for the efficient working of various nurses. As noted by National Nurses United (2018), the support was led by the Executive Director of NNU, Bonnie Castillo, who is also a registered nurse (RN).

Advocacy is another useful means by which nurses play a role in the passing of legislation. Through support, there is a focus on championing others concerning ideas and relatable societal concerns to get influence. By being part of the health system, nursing communities have essential values, exhibit professional ethics, in addition to advocacy skills and personal experiences, which makes the nurses and their leaders to possess valuable views for the formulation of health policies (Arabi, Rafii, Cheraghi & Ghiyasvandian (2014). Thus, as nurses, applying advocacy in healthcare is vital to the success of the Health Workplace and Prevention Act, as well as its success in the application. Notably, it is the nurses and other healthcare providers who can speak to policymakers for the other members unable to air their views. Also, as an integral component of healthcare provision system offering over 24 hours of care and being most affected members, nurses better understand the various issues like workplace violence, which impacts on their delivery of quality health care. Essentially, advocacy is a crucial tool for nursing communities in speaking out about the issues of workplace violence. As opposed to conflicts a confrontation seen in alternative methods, advocacy focuses on the peaceful promotion of ideas and principles.

Another useful role of nursing in the Workplace Violence Prevention Act passage gets seen from the position of a voter. As valid U.S. citizens, the application of one’s democratic rights through the voting process is vital in ensuring legislative measures meet the needs of the society. By voting or electing house representatives, nurses have a crucial role in influencing the passage of health laws, which aligns with the ensuring that there is minimal violence in the workplace. As noted by Govtrack (2018), the H.R. 5223 Act got sponsored by Ro Khanna, who is the (U.S. Representative for California State. Thus, the role of nursing in choosing leaders is critical in impacting on the subsequent passage and influencing outcomes of the process of making policies.

Finally, nurses have the role of being the major players in the implementation of the H.R: 5223 Act, through practicing its mandates, encouraging their colleagues in applying some of the recommendations and take an active role in reporting where violations or issues might arise. As a nurse, one has the responsibility of ensuring the well-being of others, and that of the patient, which occurs through the active contribution to the policy implementation process.

Through the combined support and championing of changes in health law or institution of new regulations, nurses serve a crucial purpose in realizing the public health goals. In its operation, public health legislation or policies require the input of all members of the society for success. As noted by WHO (2018), health policy entails choices, plans, as well as actions that get decisively undertaken for the achievement of specific and well-defined health care goals. Thus, with the role of healthcare policy defined, nurses have an essential role in overseeing the implementation. Also, nurses, who form a significant amount of time with patients, have a function of reporting any violations of healthcare regulations. Through the combined support and unified opinion, it gets comfortable in meeting the health facilities objectives due to the aid of nurses.

Conclusion

The role of the legislature in healthcare is well recognizable for the attainment of an efficient working environment. With workplace violence as a significant health concern, the managing of violence impacts in healthcare is essential in allowing nurse staff to work effectively. As crucial persons in healthcare, nurses must understand their place in society, recognize the power levels and make changes which leads to better care.

By taking part in policy formulations, nurses have an objective of realizing a workplace that is free from violence. Through the Health Workplace Violence Prevention Act, nurses and other healthcare workers have a better opportunity in dealing with violence issues at work. Also, with violence, there is the need for adequate post-violence incident financial and psychological support to deal with distress. In essence, quality healthcare is possible with the sufficient and timely management of health-related work violence, across the various health institutions.

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