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Research shows increased fear and anxiety can lead to escalation, agitation and violence, clinician says

It is important for supervisors to acknowledge the feelings and experiences of their staff as valid and real, says RN Heather Tuttle of Relias.

Susan Morse, Managing Editor

In a Q&A, clinician Heather Tuttle addresses workplace violence in the provider setting and what can be done to help prevent it.
Healthcare Finance News. How prevalent is workplace violence in hospitals and health settings?
Heather Tuttle. Unfortunately, workplace violence in healthcare has continued to increase across various care settings and professions. According to the National Institute for Occupational Safety and Health (NIOSH), 80% of nurses have reported incidents of verbal and/or physical violence. Possibly more alarming is the fact that these statistics are not fully representative of the issue.

For example, the Journal of Nursing Administration notes in a 2016 report that national employer data is based only on reported injuries where they missed one day of work. The lack of data is further expounded by underreporting of assault and other violent incidents, whereby staff are influenced by perception that they must care for violent patients, how much time is needed to file the lengthy reports and belief that little to nothing will come of it to prevent this from happening in the future.
HFN. Has it increased during COVID-19?
HT. There is not enough research to say that it has definitively increased during COVID-19, but there are unique considerations related to workplace violence that have been highlighted by the pandemic. Take home-healthcare – it already has inherent risk due to the uncontrolled environment, including potential factors such as weapons, drugs and unhealthy family dynamics. 

Prior to the pandemic, The New England Journal of Medicine noted that 61% of homecare workers reported violence annually. An increase in demand for these services and allotted funding during the pandemic has resulted in a major trend towards home healthcare. This spike could also possibly increase the rate of workplace violence; therefore, agencies and caregivers need to be aware of the risk presented in this setting.
HFN. What about the situation in other healthcare facilities, outside of the home healthcare?
HT. In other settings, such as hospitals and long-term care facilities, restrictions around who can enter the building have potentially cut down the overall volume of people, which could decrease the number of violent incidents. Although a 2020 Relias Media article noted that "some" reports have been made in emergency services, and references conflicts with family members of patients who have been upset with visitation restrictions.
Years of research show that increased risk of fear and anxiety potentially leads to escalation, agitation and violence. Healthcare staff are overly strained by the staff shortages, as well as the influx of patients and ongoing demand of services brought on by the pandemic. The same factors that put patients at risk for acting violently are the same that put your staff at risk for the inability to cope with that behavior.

They don't have resources to meet the psychosocial needs of their patients, let alone their own. This increase in anxiety has compounded the risk of escalating, which could lead to more violence against healthcare staff – both patient to staff and staff to staff.
 HFN. Is the violence primarily coming from patients or other sources? Is violence always considered physical, or can it be verbal?
 A. While there are reports of domestic or coworker assault, The New England Journal of Medicine states the majority of violence is from patients. Verbal is more common than physical, but both occur at alarming rates across the healthcare industry. Studies show that 39% of nurses and nurse-aides experience verbal assault, and 13% experience physical abuse on an annual basis.

Another study found that 46% of nurses reported some type of workplace violence during their five most recent shifts. One third of these nurses were physically assaulted. Emergency departments report the highest rates: 100% reporting verbal assault and 82.1% reporting physical assault during the previous year. These staggering statistics have motivated lobbying for change with Occupational Safety and Health Administration [OSHA] regulations to help protect healthcare staff.
HFN. What do you recommend healthcare providers do to avoid violent situations, and what do you recommend to care providers if and when they find themselves in such a situation?
HT. "From a prevention standpoint, it will be key for organizations that commit to demonstrating thoughtful patient-centered policies for workplace violence prevention. This would include ensuring policies are clearly articulated to patients and visitors as soon as they enter the healthcare environment and that violence against caregivers will not be tolerated.

Updating policies and procedures to incorporate strategies such as a simple process for incident-reporting, as suggested in the 2016 New England Journal of Medicine, or per the 2019 Journal of Nursing Administration, flagging patients with a history of violence to make the workplace safer. These updates, along with effectively communicating and training all staff on these updates, will be critical for accountability and effective change.

Although violence against healthcare staff was already an issue before the pandemic, the extraordinary circumstances it has created have left so many organizations struggling to keep people on the floor and employees in a perpetual state of "survivor mode," where they are only able to execute basic practices to keep their patients and themselves alive. With a lack of time and resources, they don't have the capacity for psychosocial respite in care and will eventually burnout if they haven't already.
"Therefore, it is important for frontline managers and supervisors to acknowledge the feelings and experiences of their staff as valid and real. Organizational leaders will need to provide evidence-based strategies and education for coping and care. 

  Heather Tuttle, BSN, RN, CEN, TCRN, is a clinical solutions product manager for Relias, which offers peer support and wellness courses to staff. 

Twitter: @SusanJMorse
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