Patient Abuse of Nurses & APRNs
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“Nursing students need to be aware of what workplace violence is, and its implications for their own health, workplace trust and morale, career satisfaction, as well as patient experience and quality of care.”
Lisa Stand, Policy & Regulatory Advocacy Director for Policy and Government Affairs at ANA
Abuse of nurses and ARPNs is a real, relevant, and widespread problem. The abuse can range from acts of minor bullying and incivility all the way to assault and physical violence. Recent data suggests that the number of incidents of abuse is not only significant but rising. Concrete steps can be taken to reduce it.
Every profession deals with some level of workplace violence, but healthcare experiences more than most: a report by the Government Accountability Office (GAO 2016) found that healthcare workers in inpatient facilities experienced workplace-related violence that resulted in injuries requiring time off work at a rate five to 12 times higher than workers in the private sector. Those injuries can be physical, psychological, or sexual, and the violence can be perpetrated by patients, patients’ family members, or other individuals.
Nurses and APRNs deal with patients who are sick, stressed, and frightened. They care for patients with dementia or withdrawal symptoms. These patients may be more prone to committing acts of abuse, but abuse can come from the family of a patient, or even from coworkers. According to the American Nurses Association (ANA), one in four nurses is assaulted—and barriers to reporting suggest that the problem could be even more widespread.
Defining and Measuring Incidents of Nurse Abuse
“Every RN and APRN has experienced a form of verbal or physical abuse, most often from patients, but also from colleagues,” says Erika Kaneko, RN, a Clinician Advocate at Vivian Health. “Abuse from patients is challenging as some medical conditions can alter the patient’s mood and behavior, which is something we, as nurses, have to deal with. Other times, though, patients are very intentional with their anger and frustrations and take it out on nurses.”
Data from the second quarter of 2022 showed that more than two nurses per hour suffered incidents of abuse (Press Ganey 2022). Acute, psychiatric, and emergency settings carried the highest number of assaults, while obstetrics and neonatal intensive care units had the lowest. Notably, while most assailants were patients, family members, coworkers, visitors, and intruders were also perpetrators of abuse.
“I’ve personally experienced being kicked and punched at by a patient who was dealing with a mental health crisis,” Kaneko says. “Verbal abuse from colleagues exists as well. It’s challenging, especially in stressful environments, as people’s patience, emotional bandwidth, and energy levels are stretched thin.”
Even nurses who only witness instances of abuse are affected by it. And verbal, psychological, and physical abuse can become entrenched within an organizational culture if there are inadequate processes to prevent and address it. According to the ANA, such conditions can adversely affect the quality of patient care and care outcomes, reduce a nurse’s level of job satisfaction and organizational commitment, and undermine nurse well-being.
Barriers to Reporting Nurse Abuse
“Due to the many barriers to reporting incidents of violence, it is estimated that only 20 to 60 percent of incidents are reported,” says Lisa Stand, the Policy & Regulatory Advocacy Director for Policy and Government Affairs at ANA. “Bullying and incivility rates may be even higher, causing many nurses to feel unsupported and without any options to make their workplace safe.”
Many barriers to reporting exist: from workplace cultures that perceive some amount of abuse as normal to a lack of agreed-upon definitions for abuse to the absence of a streamlined reporting system. Some nursing staff may fear retaliation for reporting an incident, while others may consider the incident too minor.
“Even if there is a place to report threats and incidents, we hear over and over again, ‘It won’t do any good,’” Stand says. “Many nurses do not believe their employers will take meaningful action on their reports. Other nurses simply believe that violence and threats of violence, even bullying from other nurses, are routine—‘part of the job.’”
ANA emphasizes that employers must set up reporting systems and promote internal cultures that encourage reporting. To monitor and maintain that culture, employers need to use data to develop additional prevention programs, and then track their progress over time. Without an organizational commitment to address nurse abuse, many nurses are left with arcane processes that exist primarily on paper.
“When you onboard as a new employee, you are required to complete modules surrounding workplace violence,” Kaneko says. “But in practice, it is a challenging space to navigate when there may be a hierarchy in the chain of command. Often, finding the time to report an incident is difficult.”
How Organizations Can Help Address Nurse Abuse
“Organizational policy is critical,” Stand says. “Most important to establishing a culture of safety from violence is a prevention program that is facility-specific, environment-specific, and leadership-driven.”
ANA’s position is one of zero tolerance for incivility, bullying, and workplace violence. A zero-tolerance policy should be clearly stated in all healthcare workplaces, including strategies for prevention and processes for reporting bullying, incivility, and workplace violence. Zero tolerance also helps remove ambiguity over abuse, which remains a significant barrier to reporting.
“Standard definitions as to what constitutes incivility, bullying, and violence would go a long way toward improving reporting and data analysis,” Stand says.
No standardized process or regulatory requirement exists to report incidents of workplace violence in the US, except for in a handful of states, and there is no central repository for reporting them (as there is in the national health systems of the UK and Australia). The law of the land is thus a fragmentary one, varying by the policies of individual healthcare facilities.
To get prevention programs in every healthcare setting, nurses are pushing for Congress to pass the Workplace Violence Prevention for Health Care and Social Service Workers Act. The bill would require the Occupational Safety and Health Administration (OSHA) at the Department of Labor to create effective standards for workplace violence prevention and thoroughly enforce them. Having previously passed the House twice but stalled in the Senate, nurses are calling on the new Congress to make it a priority.
At the same time, nursing schools can do more to prepare students on how to prevent, identify, manage, and report abuse. Training should focus on realistic scenarios and simulations that instill a culture of safety that carries over into the workplace. Introducing evidence-based processes at this early stage of the nursing pipeline can have outsized effects later on.
“Education about risks to nurse safety on the job starts in nursing school, and should continue in all healthcare delivery settings as ongoing safety and quality improvement,” Stand says. “Clearly, more is needed than a 50-minute, check-the-box module. Nursing students need to be aware of what workplace violence is, and its implications for their own health, workplace trust and morale, career satisfaction, as well as patient experience and quality of care.”