WORKPLACE VIOLENCE1
Workplace Violence Against Nurses And Its Emotional Impact
Lindsay Kurtz
State University of New York Institute of Technology
Workplace Violence Against Nurses And Its Emotional Impact
Violence in the workplace by patients against healthcare workers has been occurring for years. Traditionally, violence occurs most in healthcare settings on mental health units, in emergency departments, and critical care units. Since such violence has been present, it was seen as part of the practice and something that nurses should be prepared to handle. Violence in the workplace towards nurses was accepted. It was frowned upon to press charges or even speak about the violence that occurred due to the fact that patients were in the hospital for help and may not be in the correct state of mind when committing such acts. Unfortunately, over the past decade, the amount and degree of workplace violence against nurses has increased. Nurses are being physical injured and emotionally damaged significantly. As more nurses have come to speak of the violence and voice their concern about what has occurred, the issues brought forth are awaiting solution.
Background
Workplace violence has become a normative experience rather than a rare occurrence for nurses (Lanza, Reirdan, & Zeiss, 2006). Violence reduction has become one of the major goals of the World Health Organization. Due to the increase in violence in general society, workplace violence has also increased. The World Health Organization defines violence as, “the intentional use of physical force or power, threatened or actual, against oneself, another person or against a group or community that either results in or has a high likelihood of resulting in injury, death, psychological harm, maldevelopment or deprivation” (WHO, 2002, p.5). In 2002, WHO developed guidelines to intervene and attempt to manage workplace violence (Roche, Diers, Duffield, Catling-Paull, 2010).
Because nurses are on the receiving end of the violence, there are detrimental effects to the practice of nursing, the patients they are caring for, and on the nurses themselves. Unfortunately, there is a lack of definitions of workplace violence in individual institutions to guide reporting, intervention, legislation, and research (Howerton Child & Mentes, 2010). However, there are some things that can be concluded from the literature about workplace violence. First, nurses world-wide experience more non-fatal violence than any other occupation. Second, nurses as a whole are found to report the highest level of violence compared to other healthcare workers. And third, psychiatric nurses are the most likely of the nursing specialties to report workplace violence (Lanza, Reirdan, & Zeiss, 2006).
However, due to the social tolerance of violence towards nurses, to change this current ideation will take time and a significant change in culture, patience, and education (Roche, Diers, Duffield, & Catling-Paull, 2010). This change is beyond necessary as the impact on nurses is being more openly discussed and is impacting the profession. The nurse experiences both physical and emotional effects as a result of workplace violence. Feelings such as fear, intimidation, anger, helplessness, anxiety, and even diagnosis of PTSD are occurring due to workplace violence (Chapman, Perry, Styles, & Combs, 2009). However, the emotional and psychiatric impact of workplace violence on nurses is under-researched (Bonner & McLaughlin, 2007). Therefore, additional studies are needed to look at the emotional and psychiatric impact of workplace violence on nurses and come up with solutions for treatment and prevention.
Purpose
The purpose of this research proposal is to research the emotional and psychiatric effects of workplace violence on nurses. Once the emotional and psychiatric effect of workplace violence on nurses is known, it is crucial to determine how to treat the effected nurses and change the culture to prevent violence from occurring in the future. Nurses, the profession, and healthcare organizations are all impacted by such actions.
Significance
The significance of determining the emotional impact of violence in the workplace by patients against nurses is to understand the detrimental effects it not only has on the nurse, but also on their family, their ability to perform as they would have prior to the violent incident(s), and the impact on the organization for which the nurses practice. Once the negative effects of such violence in the workplace by patients against nurses is clearly understood, the significance of preventing such acts becomes even more critical.
Lifelong Emotional Impact
Besides the obvious physical injury that can result from workplace violence, the emotional impact can also be significant. If a nurse suffers from PTSD, clinical depression, anxiety, insomnia, helplessness, hopelessness, sadness, and/or anger as a result of violence in the workplace his/her life becomes altered (Wilkes, Mohan, Luck, & Jackson, 2010). Through this study, if such emotions can be prevented all together or effectively treated, the nurse’s quality of life in and out of work will improve. Determining not only the emotional and psychiatric impact of workplace violence on nurses, but the prevention and treatment of such is significant for the improvement of the life of the nurse and ability to provide for society.
Job Performance and Productivity
Workplace violence may inhibit nurses’ ability to care for patients with the same efficacy and sensitivity prior to the violent event (Howerton Child & Mentes, 2010) . If the patients the nurse is caring for are at risk due to the emotional impact the nurse has sustained a study concluding or suggesting how to prevent and treat such trauma is significant. Additionally, when a nurse is physically injured or emotionally unstable related to workplace violence, he or she may miss time at work which can reduce the productivity of the organization, therefore, is it significant to the profession to prevent or reduce the number of such events.
Burnout, Retention, and Recruitment
Nurses who are continuously exposed to violent workplace environments have a tendency to have increased “burnout” rates and are unable to practice in the environment in which he or she experienced the violence (Howerton Child & Mentes, 2010). In a time in the profession when numbers are already down and the average age of a nurse is nearing time of retirement, it is critical to the practice to retain nurses. Furthermore, if the workplace violence is reduced, retention will come naturally and recruitment will occur with more ease.
Research Questions
The research questions for this study are:
•What are the emotional and psychiatric effects of workplace violence on nurses?
•How does workplace violence by patients against nurses effect patient care and job performance?
•Does workplace violence affect “burnout,” retention, and/or recruitment of nurses?
•Can interventions be implemented to prevent or reduce workplace violence?
Definition of Terms
Workplace violence: any act of physical violence, threats of physical violence, harassment, intimidation, or other threatening, disruptive behavior that occurs at the the place of employment (Handbook of workplace violence, 1998)
Patient care: aspects of the health care of a patient, including treatments, counseling, self-care, patient education, and administration of medication performed by the nurse
Job performance: work performance in terms of quality and quantity that each employee is expected to contribute
“Burnout:” exhaustion of physical or emotional strength usually as a result of prolonged stress or frustration (Medical dictionary: medline plus, 2011)
Retention: the ability to keep in one’s pay or service
Recruitment: the process of attracting new employees to a place of business
Emotional: a conscious mental reaction subjectively experienced as strong feeling usually directed toward a specific object and typically accompanied by physiological and behavioral changes in the body (Medical dictionary: medline plus, 2011)
Psychiatric: relating to cases of mental disorders
Nurse efficacy: extent to which a specific intervention, procedure, regimen, or service produces a beneficial result under ideal conditions performed by a nurse
Productivity: the quality or state of yielding results, benefits, or profits
Intervention: the act or fact or a method of interfering with the outcome or course especially of a condition or process -as to prevent harm or improve functioning (Medical dictionary: medline plus, 2011)
Theoretical Framework
Lazarus and Folkman: Stress, Appraisal, and Coping
The proposed research study will be guided by Lazarus and Folkman’s theory stress, appraisal, and coping. There are three main components to the theory: stress, appraisal, and coping. Lazarus and Folkman’s definition of stress emphasizes the relationship between the person and the environment. According to their theory, there is no objective way in which to predict psychological stress as a reaction to an encounter without reference to the properties of psychological stress to the person. Therefore, psychological stress is the relationship between a person and the environment that is appraised by the person as exceeding his or her resources, taxing, or endangering his or her well-being (Lazarus & Folkman, 1984).
Appraisal of stress is necessary related to individualized sensitivity or vulnerability to certain events. Through appraisal of stress and understanding the individualized psychological events, intervention between encounter and reaction can occur. There are three levels/types of appraisal: primary appraisal, secondary appraisal and evaluation of individual coping traits and styles. There are three types of primary appraisal: irrelevant (no implication on one’s well-being), benign-positive (outcome of encounter is understood as positive and enhances one’s well-being), and stressful (includes harm/loss, threat, and challenge which have negative implications in one’s present and future) (Lazarus & Folkman, 1984). Next is secondary appraisal where the effected individual evaluates what, if anything, can be done to prevent the outcome or harm, or improve the benefits from the encounter. Also, in this process the individual evaluates and determines what coping options are available including, changing the situation, expressing one’s emotions, and/or attempting to put the encounter and result in perspective (Lazarus and Folkman, 1984).
Lastly, coping traits and styles help predict reactions to the encounter on an individualized basis. Coping traits are the individual’s innate ability to react to the encounter. Whereas, coping styles refer to the degree in which one has the ability to react to the encounter. Coping is able to be measured through various tools and instruments, primarily through classifying individuals stress in order to predict how they will cope with all types of encounters (Lazarus & Folkman, 1984).
Application of Theory to Research
Lazarus and Folkman’s stress, appraisal, and coping theory is relatively new in relation to other theories. Therefore, the research on the theory may not be as extensive. However, the theory targets and is used in specific bodies of literature where application of a theory related to stress and coping is necessary. Many researchers have applied the theory to help explain the psychological impacts of stress, how to evaluate the stress and then how to cope.
One study, “Nurse stress associated with aggression in people with dementia: its relationship to hardiness, cognitive appraisal and coping” was performed to determine if aggressive behaviors displayed by individuals with dementia increase stress in nurses. This study also re-examined the relationship between stress and hardiness. The sample consisted of 102 male and female nurses, patient care assistants, and direct care workers from 15 nursing homes or hostels in two cities in Australia. A questionnaire based on Lazarus and Folkman’s stress, appraisal, and coping theory was developed to assess each of the three main components (Rodney, 2000). Results indicated that predicting the stress of nurses in response to aggressive dementia patients is extremely complex as the level of stress is dependent on an individual’s psychological response and definition of stress. For example, an encounter may be determined as “stressful” by one individual and another person’s interpretation of the same encounter would be “irrelevant.” Results also showed, that determining the relationship between stress and hardiness is difficult to examine, and in this study showed little correlation. Lastly, the theoretical implications indicated that, “there is general research support for hardiness, challenge appraisal, secondary appraisal, and action and palliative coping in predicting stress, perhaps the prediction of fine-grained stressor such as aggressive behavior displayed by dementing elderly is another matter.” (Rodney, 2000, p.179).
Another study, titled “Burnout and coping strategies among hospitals staff nurses” examined the relationship between coping strategies and burnout. The sample included invitation of 500 random nurses from a target population of 2,500 staff nurses with a year or more of experience. With a response rate of 40%, 150 returned questionnaires were returned. Questionnaires contained components of the Maslach Burnout Inventory and the Ways of Coping Scale, created by Lazarus and Folkman (Ceslowitz-Brown, 1989). Results of the study indicated that nurses with lower burnout scores used planful problem solving, social support, self-controlling coping, and positive reappraisal. Theoretical implications from the study indicate that the application of stress, appraisal, and coping is appropriate when evaluating stress, appraising stress and such events, and implementing and evaluating coping strategies. As indicated in this study, some coping strategies are more effective for certain types of stress than others, therefore appropriate appraisal is necessary to produce appropriate coping outcomes.
Theoretical Framework Relevance to Research Proposal
Lazarus and Folkman’s theory of stress, appraisal, and coping can be used to help guide the research proposal, “what are the emotional and psychiatric effects of workplace violence on nurses?” Stress, appraisal, and coping directly correspond to the research proposal as the encounter between nurses and violent patients can be deemed stressful. Additionally, through appraisal of the encounter, it can be determined exactly how individuals respond to various types of encounters. Furthermore, evaluating how nurses respond to stress and understanding such relationship to coping traits and styles may help develop programs to assist in effective coping for nurses related to encounters of workplace violence. The theory will assist in understanding the emotional and psychiatric impact, identifying encounters that are determined as “stressful” through primary appraisal, and learning ways to prevent or cope with workplace violence.
Literature Review
An extensive review of the literature was conducted to find empirical literature, theoretical positions, and data collection sources that answer the research questions in the proposed research in the proposed study. The following databases and search engines were utilized in order to produce scholarly articles: MEDLINE, Proquest, EBSCOhost Academic Search Premier, Science Direct, CINHAL, Health Source, PsycARTICLES, PsycINFO, and SocINDEX. Additionally, advanced searches on the world wide web using yahoo and google search engines were reviewed to supplement articles found elsewhere. Search terms included: workplace violence, nurse, patient care, job performance, emotional, psychiatric, burnout, retention, recruitment, prevention, and intervention. Collected data ranged in dates from 1984 to the present.
Literature supports the increase in prevalence of workplace violence against nurses. Furthermore, the findings associated with workplace violence are even more alarming including the emotional and psychiatric impact that in turn lasts a lifetime, effects job performance, productivity, burnout, retention, and recruitment (Bonner & McLaughlin, 2007; Chapman, Perry, Styles, Combs, 2009; Currid, 2009; Jacobsen, 2007). Prevention and intervention are necessary to halt the violence (Lanza, Reirdan, Zeiss, 2006; Lanza, Reirdan, Forester, Zeiss, 2009; Wilkes, Mohan, Luck, Jackson, 2010).
Emotional and Psychiatric Impact
Emotional and psychiatric impacts of workplace violence are broad and include: physical injury, depression, anxiety, fear, frustration, helplessness, sadness, decreased self-esteem, PTSD, anger, and aggression. Secondary to the emotional and psychiatric impacts are the effects on job performance, productivity, retention, recruitment, and burnout (Chapman, Perry, Styles, & Combs, 2009; Happell, 2008, Ceslowitz-Brown, 1989).
Lifelong emotional impact. Studies have found that some nurses respond and cope differently to different levels of violence than others. With that said, some nurses are severely impacted by the violent acts and carry the weight from the incident for long periods of time, including the rest of their lives. When this occurs, their families are impacted negatively and their path in life is altered. Research indicates that often the nurses that are victims of verbal assaults are more likely to need treatment (Bonner & McLaughlin, 2007; Bonner & Wellman, 2010; Chapman, Perry, Styles, & Combs, 2009; Currid, 2009). Bonner and Wellmean (2010) conducted a study with a survey design to evaluate the effects of post-incident review as a means of decreasing the emotional effects of workplace violence. A sample size of thirty RNs was used with a return rate of 97% whom all agreed that post-incident review was a helpful means to decrease the emotional impact of violent situations (Bonner & Wellman, 2010).
Chapman, Perry, Styles, and Combs (2009) conducted a descriptive exploratory study that collected qualitative data using a written survey and interviews to understand nurses’ perceptions of workplace violence at their place of employment in the last twelve months. A total of 322 questionnaires were sent to nurses with a return rate of 34%. Nurses indicated that consequences of workplace violence were not isolated to the workplace environment as the nurses talked of taking home feelings of fear, anger and intimidation which impacted their personal relationships (Chapman, Perry, Styles, & Combs, 2009).
Job performance and productivity. Secondary to the emotional and psychiatric effects of workplace violence, studies indicate: that nurses miss days of work which reduces productivity, increased workload on co-workers related to absenteeism and/or fear, performance and ability to do their jobs is decreased, nurses feel less competent, decreased job satisfaction, and nurses avoid patients out of fear. Additionally, nurses who experience workplace violence do not feel supported by administration and more or less feel like they get blamed for their assault. Research also indicates that workplace violence has consequences to other patients as the quality of care they received is reduced (Chapman, Perry, Styles, Combs, 2009; Jacobsen, 2007; Lanza, Reirdan, & Zeiss, 2006; Roche, Diers, Duffield, & Catling-Paull, 2010).