Monday September 16th 2019

It can make nurses sick

Aiming to prevent incivility, bullying, violence

During her career as a nurse working both in multigenerational and pediatric emergency departments, Deena Brecher has been on the receiving end of some frightening and violent behavior. She can recall taking care of an intoxicated adolescent who was spitting and kicking at her and another nurse. In short order, Brecher was hit, and the other nurse suffered a neck injury when the patient ripped off her necklace. In another incident, Brecher was threatened with a knife while working triage.

“Even though a security guard was two feet behind me, it was still scary,” said Brecher, MSN, RN, APN, ACNS-BC, CEN, CPEN, immediate past president of the Emergency Nurses Association. “It puts you on alert.”

Dianne Jacobs

Dianne Jacobs, MSN, RN, also has stories to share, but about another all-too-common and disturbing workplace problem within health care: bullying.

“I’ve had nurses tell me they have checked their schedules to see if the perpetrator was working their next shift,” said Jacobs, an expert on eliminating disruptive behaviors in the workplace and a South Carolina Nurses Association member. “If the perpetrator was scheduled to work with them, the nurses sometimes called in sick. They felt a tremendous amount of stress about a possible confrontation with that person.”

Working in an environment where damaging behaviors — from incivility to physical violence — go unchecked can have equally damaging effects on nurses’ health and well-being.

And while the American Nurses Association has long engaged in educational and advocacy campaigns to address harmful and dangerous conduct, in December 2014 ANA stepped up its efforts by convening a professional issues panel on workplace violence and incivility. The panel’s goal has been to develop a position statement that provides employers and nurses with practical, specific recommendations they can use to stop workplace violence, bullying and incivility. A draft document was posted online for public comment through April 30, and the final document is expected by August.

Once approved, the document will join a number of resources ANA has created to address these workplace hazards, along with those offered by ANA’s state nurses associations and organizational affiliates, such as ENA and the American Psychiatric Nurses Association.

Along a continuum

ENA has been bringing heightened attention to the prevalence of workplace violence for several years, including by using data from its nationwide surveys to drive home the criticality of the problem. In its November 2011 Emergency Department Violence Surveillance Study, ENA noted that the ED, psychiatric units and nursing homes were the most dangerous work settings where RNs frequently faced physical and verbal abuse from patients and visitors.

Deena Brecher

Brecher, co-chair of the ANA panel, added that more than half of nearly 7,200 emergency nurses reported experiencing verbal or physical abuse in a seven-day period before being surveyed. Further, many didn’t report the abusive episode to management, said Brecher, who early on in her career viewed violence as an inevitable workplace hazard.

That way of thinking has been so common that Jane Lipscomb, PhD, RN, FAAN, a Maryland Nurses Association member who also is on the ANA panel, wrote a book called Not Part of the Job: How to Take a Stand Against Violence in the Work Setting.

Lipscomb also points to the relationship among incivility, bullying and violence.

“Nurses who are working in settings where there is a high risk for bullying are also at high risk for workplace violence,” said Lipscomb, professor at the University of Maryland Schools of Nursing and Medicine. That’s why it’s so important that nurses and management work together to ensure there is a comprehensive health and safety program in place to address the full spectrum of harmful behaviors.

Further, incivility and bullying have been so prevalent and detrimental to patient safety that The Joint Commission issued a sentinel event alert in 2008 to put an end to these disruptive behaviors among health care workers. Yet, they continue.

The toll on nurses

Injuries to nurses from workplace violence, incivility and bullying can be obvious or hidden, and can run the gamut from minor to fatal. In the past few months, several violent episodes at health care facilities made national news. In one instance, a video captured a patient at a Minnesota hospital chasing nurses while brandishing a metal pole. One nurse reportedly suffered a collapsed lung and another a fractured wrist in the attack.

In 2013, health care workers reported about 9,200 workplace violence incidents requiring time away from work to recover, according to a NIOSH website blog.

Musculoskeletal injuries — some career-ending — are very common, as is psychological trauma and post-traumatic stress disorder, said Brecher, who often speaks nationally on this issue.

“I know nurses who had to leave nursing because of traumatic brain injuries and post-concussion syndrome,” she said. “One-third of nurses consider leaving their job or profession because of workplace violence — and that’s a huge number.”

Lipscomb drove home the point of workplace violence throughout settings.

“A large percentage of nurses say they work in fear for their safety,” she said. “Being in a constant state of hypervigilance can lead to metabolic syndrome and many unseen consequences.”

Nurses also have left their jobs or the profession because of bullying and other uncivil behaviors, said Jacobs, a psychiatric-mental health nurse, and co-founder and principal of CoMass Group LLC, which provides education and training to create safe and civil workplace cultures.

“These types of behaviors are very disruptive to nurses, causing stress that just snowballs,” she said. “And most nurses don’t know how to deal with it, which adds to their stress. They begin to think there is something wrong with them and to question their own skills and competency.

“And it’s difficult for them to be fully engaged with their patients when they’ve just been blindsided by their colleague and are still reliving the encounter.”

Further, research has shown that high and enduring stress levels can lead to a range of ill effects, from insomnia to cardiovascular issues to diabetes, among others.

What can be done

Jane Lipscomb

“So many organizations have statements about zero tolerance [for bullying and violence],” Lipscomb said. “That’s not what’s going to make a difference. All organizations and facilities need a comprehensive safety management program in place that is constantly being re-evaluated and improved upon. That’s what will make a difference.”

That program should include interventions to address affected nurses’ emotional and psychological injuries, as well as ongoing support for RNs — not just post-injury or post-incident, according to Lipscomb. Additionally, teams need to conduct an objective debriefing on how a violent episode occurred and how to improve processes for preventing it in a way that is blame-free.

She added that in the draft document, ANA takes a strong position calling for the implementation of comprehensive safety plans, and the importance of employers and nurses working together to address the entire range of harmful and violent behaviors. It provides detailed recommendations for both employers and nurses.

Brecher maintained that it’s critical that nurses report incidents of workplace violence. It’s also important to try to make the worker’s compensation process as “uncomplicated as humanly possible” and provide nurses with psychological support through an employee assistance program or other resources.

“As nurses, we all have to say we’re not going to tolerate this anymore,” Brecher said. “It’s so important to create a safe environment for everybody, and it’s our job to make the needed culture change. So I urge nurses to read ANA’s position statement on incivility, bullying and workplace violence and seek out other resources.”

Jacobs, an ANA panel member, also offered some practical advice for nurses who are faced with disruptive behaviors, such as snide remarks, gossip, sabotage or being bullied by a peer or other health care professional.

Nurses who are targeted need to talk with their manager, a trusted mentor or a good friend and discuss what’s been happening to them and how they might handle it. They also need to learn how to address the perpetrator’s bad behaviors directly, Jacobs said. Once the decision is made to confront the perpetrator, it is important to prepare and practice what they want to say. Ask to speak with him or her privately and address the person in a direct yet respectful manner. They may also want to have a witness present.

“We’re not formally taught how to deal with these situations,” she said. “Some people are better at it than others. It takes building strong communication skills — and practice. We also need to empower bystanders who can walk over to support a colleague who may be in an uncomfortable situation.”

And finally, practicing deep breathing exercises and learning other relaxation techniques will be helpful in managing the extreme stress and anxiety these toxic situations cause, and will allow nurses to be fully present for their patients.

“Nurses have such precious little time with their patients as it is,” Jacobs said. “We need to be able to do what we’ve been trained and love to do in a safe and healing environment that supports the health and well-being of patients and nurses.”

— Susan Trossman is the senior reporter for The American Nurse.


ANA statements and tools on workplace violence and incivility:

Not Part of the Job: How to Take a Stand Against Violence in the Work Setting, by Jane Lipscomb and Matt London:

Emergency Nurses Association studies and toolkit:

American Psychiatric Nurses Association position statement:

National Institute for Occupational Safety and Health training and education, other information: and

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