Running head: VIOLENCE AGAINST NURSES IN THE WORKPLACE

Violence against Nurses in the Workplace

Ashlee Burnam, Amanda Diniz, Katarina Kent, Savannah Perez, JoAnne Saba, and Ana Uy
California State University, Stanislaus

VIOLENCE AGAINST NURSES IN THE WORKPLACE

Violence against Nurses in the Workplace

Background and Significance
Workplace violence towards nurses in a healthcare setting is an existent problem.
Violence may be obviously prevalent and somewhat expected in some fields of work such as
public safety, but much light is not shed on violence towards nurses. A nurses job is to care for
others, thus, violence towards nurses can be seen as fairly incongruous. Physical violence
against nurses has become a pandemic problem, affecting nurses in nearly all work environments
(Gates & Gillespie, 2013). It happens in almost all patient care settings, including
medical/surgical, obstetrical/gynecological, emergency, psychiatric/behavioral, intensive care,
pediatric, and long-term care settings (Gates & Gillespie, 2013). All nurses are at risk for
experiencing violence from patients, however, psychiatric nurses have an increased risk due to
the violent behavior displayed by patients in psychiatric wards (Merecz, Rymaszewska,
Mocicka, Kiejna, & Jarosz-Nowak, 2006). Still, it can be argued that emergency room nurses
are the ones that are most commonly victimized (Luck, Jackson, & Usher, 2006).
Since nurses interact with patients more than other health care providers do, patients most
often direct their frustrations towards their nurses (S. Celik, Y. Celik, Agirbas, & Ugurluoglu,
2007). Once exposed, nurses attitudes might change towards the way they attend to patients,
resulting in a decreased quality of care (Blando, OHagan, Casteel, Nocera, & Peek-Asa, 2013).
The violence that some nurses face is so bad it can cause them to think about changing
professions (Roche, Diers, Duffield, & Catling-Paull, 2009; Celik et al., 2007). The enforcement
of policies or lack of policies contribute to physical violence, therefore, primary prevention
strategies are important to help reduce the incidence of physically violent situations. An
effective workplace design that utilizes security and safety devices can serve as a prevention

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strategy that allows staff to safely egress from violent situations until help arrives (Gates &
Gillespie, 2013). Even having nurses know what the risk factors, signs, and appropriate
measures to take in relation to violence directed towards them, may improve their overall
experience in the clinical setting (Zeng et al., 2013). Nonetheless, many nurses do not see
violence prevention as a priority because they feel that it interferes with other more important
nursing responsibilities (Yang, Spector, Chang, Gallant-Roman, & Powell, 2012).
Consequently, the incidences are underreported although the number of violent acts committed is
high (Luck et al., 2006). The violence directed towards nurses causes several negative side
effects such as acute stress, posttraumatic stress symptoms, decreased work productivity,
physical injury, and sometimes death (Gates & Gillespie, 2013; McKinnon & Cross, 2008; Zeng
et al., 2013). Abuse, whether physical or emotional, should not be tolerated, especially when the
victim is making an effort to help the perpetrator.
Literature Review
The purpose of this study was to describe the acts of physical violence against emergency
nurses that were perceived as stressful and to describe how the acquired information can benefit
nurse leaders and risk managers as they develop prevention strategies to prevent physically
violent situations (Gillespie & Gates, 2013). This study used a systematic random sample of
3,000 emergency nurse members of the Emergency Nurses Association, 177 of which provided
narrative descriptions of physical violence in the workplace. A qualitative descriptive design
was used and the data was analyzed using the constant comparative method. Four themes were
identified throughout the research: personal work factors, workplace factors, aggressor factors,
and assault situation. The findings indicated that close contact increased the likelihood that an
emergency nurse will become the victim of physical violence and that emergency nurses

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perceive patients with mental health diseases or patients that were under the influence of drugs
and alcohol more likely to commit physical violence.
A strength of this study is that they mentioned their theoretical framework as The
Ecological Occupational Health Model of Workplace Assault. This study was also approved by
the university Institutional Review Board and the Emergency Nurses Association, which
provided protection of human participants. The four themes of personal work factors, workplace
factors, aggressor factors, and assault situation can apply to other areas besides those mentioned,
which improved transferability. Participant member checking and prolonged engagement with
the data by two investigators provided the study with credibility. Confirmibility was achieved by
verifying accuracy of transcribed verbatim data. The quotes used in this study matched the
conceptual ideas, which also provided credibility. There was no mention of professional
member checking, which is a limitation to the credibility. Although the sample size of 177 is
large for a qualitative study, the researchers did not mention that data saturation was achieved,
which makes the sample size inadequate and serves as a weakness.
The purpose of this study was to examine the acts of violence that nurses undergo in the
emergency department and how they respond to such acts (Luck, et al., 2006). The sample size
was 20 full-time or part time registered nurses. The design chosen for this study was a
qualitative, instrumental case study. The findings of the study were the following: nurses were
affected by violence in a health care setting if the acts committed towards them were personal, if
patients are not psychologically disturbed, and if the patients were violent, when only in the
hospital for minor reasons.
There are some limitations to this study. For instance, there was no mention of whether
or not saturation occurred within the sample size of twenty nurses. No theoretical framework was

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ever given within the article. Although this article was said to be a case study design, the sample
size was larger than one. On the other hand, many strengths were found within the article.
Protection of human participants was incorporated by having voluntary informed consents and
by receiving the ethical approval from the university and hospital of ethics committees.
Furthermore, an acknowledgement of the limitations of the study strengthened the credibility.
Quotes used throughout the study also strengthened the credibility and transferability of the
findings to not only other ER nurses, but also the nursing community as a whole. An adequate
time was allotted to understand the phenomenon of the study and member checking was
conducted often throughout. After interviews and observations of the nurses were carried out, a
verbatim transcription was done on a computer located on site. The data was managed by the
NVIVO 2 software program, which then helped the researchers analyze it. When answering the
research question, codes and themes were reviewed contextually, contributing to the rigor of the
study.
The purpose of this non-experimental descriptive study was to determine the frequency of
violent acts in mental health facilities, what types of acts occur, who the victims are, and if any
relationship exists between acts of violence and the age, gender, skill level, and place of work of
the victim (Mckinnon & Cross, 2008). The sample included 63 nurses from two adult
psychiatric inpatient units and from community-based teams. To collect data, the researchers
used a descriptive survey, which compiled 16 items from other studies along with new questions
to address specific themes from the Mental Health Services. Each of the questions aimed to
provide insight into violence and assault in the workplace as experienced by staff. Participants
returned their questionnaires through the internal mail system. It was found that there is a
significant difference between men and women with occupational violence usually abused by

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men. Patients were found to be the most frequent offenders using verbal abuse most often.
There was no significant data relating to the demographics of the nurse and amount of
altercations against him or her. It was also noted that most participants had been injured as a
result of the violence as well as having been afraid while at work.
There are few strengths to this study. The first is that there was regard to the protection
of human participants and approval gained through the Human Research Ethics Committee. The
statistics used were appropriate and were found to be statistically significant as well. This study
presents far more limitations. The sample size used was too small for the type of research
design. Additionally, there was no power analysis done to determine an appropriate sample size.
The limited sample also presents a threat to external validity since the results cannot be
generalized. Internal validity also is threatened because it is unknown if the instrument used had
proper calibration, therefore, there is uncertainty of reliability. There is also a possibility of
selection bias since the researchers used a convenience sample rather than a random sample.
Lastly, the authors did not state a theoretical framework for their research.
The purpose of this article was to relate patient outcomes and the nursing work
environment to nursing staffs own perceptions of the violence they experienced, including
actual, threatened and emotional violence (Roche et al., 2009). The amount of participating
nurses in the study consisted of 2,487 with an 80.3 % response rate. The sample was taken from
21 randomly chosen hospitals in two states of Australia consisting of 94 nursing wards. The
design was cross-sectional and non-experimental by the use of a nursing survey. There was a
higher finding of perceived emotional abuse compared to actual violence and threats. Violence
was correlated with ward instability such as lack of leadership, unanticipated changes and
proportion of patients awaiting placement. There was less of a correlation between perceived

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violence and patient outcomes.

For the intent of correlating the wanted factors by the use of surveys in a relatively short
period of time, the cross-sectional design was appropriate for this study. Another strength to this
study is that limitations were discussed by the authors including the short time span during which
the study was conducted. There are no threats to internal validity as there were no historical
events to impact the data collected, no maturation, no testing threats, no mortality, and no
selection bias due to randomization. Ethics approval from 18 committees was obtained to
protect the human participants. The statistics provided did support the findings discussed.
Limitations of the study, however, were found. The researchers inferred cause and effect which
is inappropriate for this type of design. There is a threat to external validity as the study was not
completely generalizable since there was no discussion of age, gender, or ethnicity of
participants. This article only studied violence in the medical/surgical units in Australian
hospitals. The sample size was not obtained from a power analysis, however, it was stated
before the study was discussed that all of the nurses in the participating hospitals were asked to
participate. The last limitation to the study is that there was no direct statement of a theoretical
framework.
The purpose of this two-wave longitudinal correlational study was to simultaneously
examine the nurses perceptions of violence prevention climate as potential precursors to
physical violence exposure and the physical symptoms nurses developed as potential
consequences of it (Yang et al., 2012). A sample size of 176 nurses voluntarily participated to
take a survey about their exposure to violence within the past year at Time 1 and again six
months later at Time 2 regarding their exposure since Time 1. According to the study, the
nurses views of violence prevention as a hindrance to other seemingly more important work had

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significantly predicted exposure to violence and that all of the physical symptoms except for the
upper limb pain were significantly affected by a change in exposure. The findings suggest that if
nurses did not view violence prevention climate to be inferior to other work, then there will be a
decrease in physical violence exposure, hence an increase in their overall physical well-being.
Some of the limitations of this study are the lack of a power analysis, lack of a statement
of the theoretical framework, and threat to internal validity due to selection bias caused by
convenience sampling. Furthermore, since the study was conducted in one geographical region
and the subjects were, on average, 45 year-old nurses with job tenure of about 17 years, it may
not be as generalizable, thus presenting a threat to external validity. Conversely, some of the
strengths of this study include the protection of human participants as evidenced by the
participants informed consents and the approval of the Institutional Review Board, the statement
of the studys limitations, the application of the appropriate statistical analysis tool, and the use
of instrumentation developed and accepted by other researchers. Also, the reliability of the tools
was depicted by a Cronbachs alpha coefficient greater than 0.7 for the internal consistency
reliability of the violence exposure and prevention scales. However, this was not applied to the
tools used for the physical consequences portions due to their formative construct.
The purpose of this study was to determine the prevalence and risk factors of workplace
violence towards psychiatric nurses and to assess how this violence affects their quality of life
(Zeng et al., 2013). The design that the researchers used for this study was a cross-sectional
survey. This study included a sample size of 387 psychiatric nurses from two hospitals in China.
The results of this study found that 82.4% of the sample of nurses admitted to experiencing at
least one type of violencephysical, sexual, or verbalwithin the last six months. In addition,
almost two thirds of the 387 nurses reported feeling threatened during more than 20% of their

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hours of work in the past week. The risk factors that this study found that increased the chances
for the nurses to report experiencing higher instances of violence included working on a rotating
duty, having worked as a nurse less than ten years, being a male, and having a higher education.
This study also found that the nurses who experienced violence in the hospital on a regular basis
had a lower physical and mental quality of life.
There are a number of strengths and weaknesses to this study. Stating that the study
gained clearance by the Clinical Research and Ethics Committee, having the participants respond
to the survey anonymously, and maintaining confidentiality when handling the surveys signified
the protection of human participants. The researchers also used a power analysis to determine
the size of their sample and had a sample size that was compatible within that range. The
researchers of this study also used statistical analyses that were appropriate for their data and
included both genders in their study. A weakness is the lack of statement of a theoretical
framework. Furthermore, this study lacked in randomization since it included a convenience
sample of nurses from only two local hospitals in China. Also, one of the tools used had
inadequate validity, since it was only used for this particular research study.
Implications for Nursing Practice

Providing an orientation to patients and families to teach them the nurses role in order to
outline that violence in the workplace is unacceptable and not tolerated.

Knowledge of patients with a violent history may help nurses protect themselves against
physical violence by interacting differently with these patients.

Implementing skills training on violence in the hospital would allow nurses to feel more
adequate at assessing risk factors for violent patients and help them to discover new skills for
handling the behavioral and emotional problems of psychiatric patients.

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Proper management of the unit floor, such as having the proper ratio of nurses to patients,
could help decrease violence by decreasing the tasks and stress level of nurses.

In order to address the quality of life issues that many nurses face after being exposed to
violent attacks, counseling services should be provided for nurses who would like access to
them.
The findings of this review identified several risk factors for violence against nurses

including close contact, being a nurse for less than ten years, and working with patients that have
a mental illness or are under the influence of alcohol. Nurses who experienced violence on a
regular basis had a lower physical and mental quality of life and the reports indicated that the
effects of violence lasted longer than just the immediate exposure. These studies examined
several gaps in the literature, including which acts of physical violence were perceived as
stressful to nurses, the extent that perceived violence against nurses affects their quality of life,
as well as the nurses perceptions of violence prevention climate as potential precursors to
physical violence exposure. However, future research still needs to be performed to measure the
frequency and severity of effects of violence on the worker, workplace, and patient care. This
research needs to include additional precursors and consequences of violence to achieve an even
better and more complete understanding of the causes and outcomes of violence exposure.

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References
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Celik, S., Celik, Y., Agirbas, I., & Ugurluoglu, O. (2007). Verbal and physical abuse against
nurses in Turkey. International Nursing Review, 54(4), 359-366. doi:10.1111/j.14667657.2007.00548.x
Gillespie, G., & Gates, D. (2013). Stressful incidents of physical violence against emergency
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department nurses ascribe to individual acts of violence. Journal of Clinical Nursing,
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