Workplace violence towards nurses – what are the indicators?

This entry is part 1 of 3 in the series Violence against nurses

Health care workers must routinely handle patients who are delirious, agitated and even aggressive, especially on psychiatric units, in EDs and nursing homes.

Sometimes when these conditions escalate they become full scale assault – and nurses are often the victims.

Clear legal basis needed to combat violence against women

The September 2006 issue of the Journal of Advanced Nursing reported that in 2002, almost 64% of 2400 Tasmanian nurses said they had suffered either verbal or physical abuse during the four weeks prior to the survey.

Psychiatric and emergency settings show the highest levels of abuse. Patients perpetrated the vast majority of instances of physical (97%) and verbal (74%) abuse; other sources were visitors and colleagues. The studies show that of those physically assaulted on the job, 38% talked with a colleague afterward and only 19% filed a formal report.

There are numerous reports in the media of nurses being injured, or worse, by patients.

Just last week the death of a Filipina nurse working in a California jail raised concerns over the “disturbing trend of violence” faced by medical care professionals in potentially violent workplaces.

On October 28, registered nurse Cynthia Palomata, 55, succumbed to the head injuries she sustained when she was attacked by an inmate at the Martinez county jail, where she had been working since 2005. The prisoner faked a seizure attack to get out of the waiting room, then, without provocation, hit Palomata on the head with a table lamp.

Surely there must be some warning signs – so what are the indicators of workplace violence?

The USDA Handbook on Workplace Violence Prevention and Response outlines the following as potential signals for general workplace violence prevention (not specifically hospitals)

  1. Intimidating, harassing, bullying, belligerent or other inappropriate and aggressive behavior.
  2. Numerous conflicts with customers, co-workers or supervisors.
  3. Bringing a weapon to the workplace (unless necessary for the job), making inappropriate references to guns or making idle threats about using a weapon to harm someone.
  4. Statements showing fascination with incidents of workplace violence, statements indicating approval of the use of violence to resolve a problem or statements indicating identification with perpetrators of workplace homicides.
  5. Statements indicating desperation (over family, financial and other personal problems) to the point of contemplating suicide.
  6. Direct or veiled threats of harm.
  7. Substance abuse.
  8. Extreme changes in normal behaviors.

Have you experienced violence in the workplace? How do you deal with it?

What indicators are there from patients who may be a threat?

Image credit: European Parliment

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  1. Some years ago, my uniform included wearing a tie, being an ADN. A patient I walked past in ED grabbed the tie, tried to choke me (must be his hobby at home, as I only just walked into ED and he was sitting there). Then he dropped, and tried to swing from the tie (did I look like a swing?), so I pulled out the 14-inch Mayo scissors I had in my pocket ( as you do when you’re not allowed to carry a knife! – made me feel like I was walking the streets of Mt Druitt again!), cut the tie, and let him hit the ground.

    Recently, I walked into ED, and was asked :”would you go and take X’s BP??? – he’s behind the curtain!? ) – why are patient’s in ED behind a curtain, when they’re supposed to be sick enough to be in ED?
    I pulled the curtain open, just in time for his walking stick, on full swing, to smash into the side of my face, and blow a hole in my cheek that I could put my little finger into. 6 sutures, and back to work 20 minutes later. He told me he thought I was his son, and that if I knew the son that I’d have done the same!

  2. What a life you’ve had Bernhard !!!

    The topic is quite relevant to all areas of Nursing, but I’d have to say, all of those precursers mentioned in the list from the USDA are NOT issues one would expect to see displayed by Nursing staff members.

    Some of them ‘may’ be seen in a psych. unit, but not in the staff !! ( I hope )

    My main comment would be….. that I feel that certain areas of Nursing should be given a ‘personal risk’ rating. In order to work in an area that is rated ‘high’ for personal risk to health & safety, you need to be accredited in ‘personal safety for staff’. This may be in the form of doing a specialised ‘In Service’, that adequately prepares staff for the very specific threats involved. Or it may simply be, that only ‘senior’ Nurses, with say 10 years min. can work in that particular area ( Eg. a forensic psych unit )

    The EEO notion, that every Nurse is equal just doesn’t work. Juniors are getting into trouble in places like EDs, Psych, jails, and yes, even dementia wings of Nursing Homes !!

    Certainly in the Public Sector, management must be made to be accountable for sending a first year RN, with no real life experience ( your 21 yo female RN, ex Catholic School – never been away from home before type kid ), into a full on Forensic Prison Hospital !!! ( hopefully, we will get to see the level of corruption in the system, after the inquiries into a Sydney establishment !! )

  3. As an AIN at a Nursing Home and working in the SCU I have to be on my toes….getting ready to avoid fist is a regular part of my job.
    I have had a hard cover book thrown at me but have been so lucky to have not had a fist connect. There has been a few times where the male residents become very upset and get ready to hit us so it takes two AIN to assist to there needs.
    Nursing sure is one job that is full of surprises.
    Nursing Issues –

  4. I think we have to accept that working with people is unpredictable and we are going to be at risk of violence and aggression whilst at work. This does not mean that we should tollerate it though. There are normally warning signs of aggression and the rest of the team should be notified to take precautions. Security should also be made aware of potential problems. Reading around the subject suggests the biggest contributing factor is poor communication. I agree with this for most cases but you have to accept there are some nasty unpredictable people out there who don’t need a reason to become violent or aggressive. My advice is be aware of the risks, take steps to reduce the risks and don’t tollerate this behaviour. Surely thats what zero tollerance is all about.

  5. Only in nursing would the victim of workplace violence be blamed for it. About 18 months ago I was assaulted by a patient who was a significant management problem, who had assaulted other staff and continued to do so after I was injured. The first thing my NUM said to me was “have you attended aggression management?”, as if I was the aggressor. Since then I have attended aggression management, had surgery for one of my injuries and am on return to work duties. I may never return to the bedside, so debilitating are my injuries.

    The thing that probably galls me the most is that I have never received an apology. If a patient is harmed during their treatment, there is the whole open disclosure and apology palaver, but a staff member can go jump.

  6. i have also been hit by pts with dementia i have als nursed pt with agression problems if they know that their behaviour will not be tolerated its amazing how they can change their ways…

  7. What gets my goat is when a violent patient is specialed by a nurse who is so small in statue that just one punch will be enough to cause him or her grevious bodily harm. Bringing this up with admin they talk about EEO. Duty of care for the nurse is far more important in cases such as these.

  8. I’ve been nursing for 36 yrs and I am fed up of violence from patients, staff, colleagues also the lack of support for the assaulted staff member. Recently I was assaulted by an allegedly “sweet” 80+ female in a small private med/surg private hospital.
    I was very upset and hurt physically. The attitude of the management when i pointed out that the risk assessment hadn’t been completed, this patient had been habitually drinking 6 – 7 large gins a day. Oh well you could do it on night shift.
    Its a bit late post op when this sweet person turns into something from the exorcist, and you have you jaw put through the top of your head.
    I received no support from the management, OH&S committee, my GP or peers. The attitude is just suck it up. Thanks to the NSWNA for hearing me out. Also to my best friend for supporting me
    If I had sustained a longer lasting injury, should I have this person charged with assault? Can you imagine the media kerfufle. Nasty nurse sues sweet little old lady. You’re damned if you do and damned if you don’t. I’ve gone from loving nursing and being a passionate nurse to counting the days till I retire, 3 yrs, 8 months

  9. As someone from outside the nursing profession, a patient having undergone surgery to remove a tumor, nurses have earned my utmost respect and admiration, they saw to my every need and played a significant role saving my life with genuine care and concern.

    I think that there needs to be a ward set up especially for high risk violent patients, eg remove objects that can be used as weapons, rooms with doors that lock from outside with observation windows (without looking like a prison cell) and beds provided with restraints (obscured until required), to prevent a patient lashing out at a nurse while they work, no nurse should be put at risk and should always be accompanied by trained security (wearing similar uniforms to nursing staff, so it doesn’t threaten the patient, we want them to calm down if possible). Hospitals should also have access to criminal records to assist with risk assessments and sufficient resources provided to efficiently do so.

    The nurses safety needs to come first, a patient should have the right to refuse care or treatment, but must not be allowed to cause harm either.

    I work in the mining industry, the government should provide similar safety legislation to hospital staff, unfortunately governments are prone to double standards because they’re also the employer. On a mine site, every job requires a risk assesment and hazards must have controlls in place before commencing work.

    Mines inspectors have the power to close a mine site if necessary. Mine managers can face gaol terms if they haven’t discharged their safety obligations under the act.

  10. What we need is access to having violent patients charged with assault. A colleague of mine was assaulted last week at work and was told by the after hours manager “that’s the nurses lot” When the victim wanted something done about it. These managers should also have more accountability for assaults occurring in their wards when they fail to take measures to reduce the risk of injury to staff.

  11. Hi everyone,

    Some of our friends in nursing have talked about similar stories related to nurse abuse and on-the-job violence. In Victoria for instance, it seems that things haven’t improved enough since the initial Victorian Government enquiry on violence in nursing in 2005, and the more recent government plan to introduce armed security officers in emergency departments. It shouldn’t be too much to ask for a safe workplace for nurses like many other professions.

    Against the back-drop of staff shortage and ever-increasing workload, we think having the essential skills in self-defense plays a big part here, to help deter abuse and violence in nursing. After all, time off-work due to physical injury and mental trauma inflicted by aggressive or violent patients means the nurses’ livelihood and their loved ones are directly affected.


  12. We recently had a middle aged man on our medical ward with a long Hx of ETOH and brain damage from the amount he has drunk in his lifetime. When he absconded from the ward to buy a large bottle of spirits, which he snuck back onto the ward and drank the entirety of within 1/2 hour, he became belligerent, verbally agressive and physically threatening. We were told by the hospital nursing management to “just ignore it” and call security if he became uncontrollable.
    I was flabbergasted at this reply – especially when the Drs had said he was medically discharged and only awaiting hostel placement. Should we have told the other 29 patients on the ward to “just ignore him” too, even when he would go into their rooms and start rummaging through their belongings? Why this man wasn’t told to pack his bags and be escorted off the premises was beyond me. I understand that as nurses we often have a duty of care to those patients who require it, but not at the risk of serious physical injury to ourselves. There needs to be a safer guideline set in place to avoid these kinds of situations.

  13. Having worked in psychiatric units for over 25 years, the level of violence and aggression towards nurses is not only seen as an acceptable part of your employment, it’s expected to be tolerated. If doctors or NUMs were physically and verbally assaulted, would things change? Maybe? Today’s patients present with an illness as well as a substance abuse addiction. And for the most part nurses are expected to use least restrictive practices when dealing with aggression. Chemical restraint seems to be the last resort that doctors use when dealing with patients. They have never been throttled. Doctors need to get onboard and prescribe so that nurses are not living with the threat of injury and chronic pain.

  14. It is expected and it’s not on. As a disability worker, Iv’e been punched, hair pulled out, had to run away and hide from violent patients, earring ripped out, back, neck and wrist injuries, just in doing my job. Then the other staff get into the mix with overestimating your timetable and putting too much demand on your time, bullying, but I have yet to be hit by any of them.
    As nurses, we have a duty of care to our patients, but where do we draw the line?


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