Will a Violence PreventionPlan Reduce the Negative Effects of Workplace Violence?

Joan Herr

Grand Canyon University

Professional Capstone Project

NRSV 441

Dr. Joyce Morrison

March 08, 2011



Workplace Violence (WV) is increasing at an alarming rate especially in the hospital setting (Dickinson, 2009, p. 34). Nurses have the second most dangerous profession (Gallant-Roman, 2008, p. 450). The definition of and effects of WV will be identified in this capstone project. Most facilities do not have strategies in place to deal with WV (AbuAIRub, Khalia, & Habbib, 2007, p. 281). Suggested solutions to minimize the effects of WV will be presented in order to minimize the dangers to the employee, reduce costly expenses of WV, and to improve the quality of care and patient satisfaction that are negatively affected by WV. An extensive review of the literature will be provided to support all aspects of capstone project. A theory to reduce the negative effects of WV will be discussed. Methods to educate, implement, evaluate, and disseminate results of the WVplan will be presented.


Will a Violence Prevention Plan Reduce the Negative Effects of Workplace Violence?


On January 8th, 2011, Americans were shocked upon hearing the morning news.The news reported that an Arizona congresswoman, Gabriel Giffords along with at least 17 others were shot outside a neighborhood Safeway grocery storeby a suspect who had previously displayed increasingly strange behavior (Lacey & Herszenhorn, 2011, p. 1-2).

Violence in our world is a common occurrence. Workplace Violence, (WV) is a situation that occurs on a daily basis for many employees. WV can be bullying, verbal abuse, harassment, inappropriate sexual comments or actions, and can also be violent threats or actions (Ventura-Madangeng & Wilson, 2009, p. 37). WV can be from fellow employees, patients, or visitors. The true incidence of WV is undetermined and considered under-reported due to many factors (Ventura-Madangeng & Wilson, 2009, p. 37). This underreporting can occur due to nurses feeling it is just part of the job, concern over repercussions or simply because the definition of WV has never been standardized (Ventura-Madangeng & Wilson, 2009, p. 38). Many facilities do not have WV preventions plans in place. Violence in the workplace is anticipated to rise in the future due to the strained economic conditions that exist (Hoobler, 2006, p. 229). WV has many physical, psychological and financial effects that are costly to the employee, the patient and the institution.Facilities that recognize WV as a problem and have instituted WV prevention plans note a drastic decrease in its incidence Keefe, 2011, p. 10).It is time for organizations to begin to identify WV as a huge problem before the effects of its lack of recognition as a problem and lack of planning to prevent it are beyond solutions and the end result is disasters such as occurred on March 8, 2011 to Congresswoman Giffords.

Problem Definition

Problem Identification:

According to the American Nurses Association (as cited by Gallant, 2008, p1.),

“Nurses have the right to a safe and secure workplace in which to provide quality patient care.” Due to the presence of WV, a safe place to practice nursing is not the reality that most nurses practice in.

Problem Description

Verbal abuse, harassment, bullying, sexual abuse, and physical violence are all part of what many nurses consider to be “part of the job”(Keefe, 2011, p. 10), and are all terms associated with WV(Ventura-Madangeng & Wilson, 2009, p. 37). WV may come from patients, visitors, or coworkers. Wherever people are under considerable conflict or stress, this increases the chances of WV occurrence (Holmes, 2006, p. 222). In the hospital setting, Emergency Departments (ED) and Mental Health Units appear to experience the highest number of violent incidents (Chapman, Sytles, Perry, & Combs, 2010, p. 479). According to the Emergency Nurses Association, (ENA), (Keefe, 2011, p. 10), 8-13% of ED nurses are victims of physical violence at work every week. Most occurrences of WV occur in a hospital room. Police officers have the first highest incidence of violence; nurses are second (Spector, Coulter, Stockwell, & Matz, 2007, p. 119).

Impact of Problem

Workplace violence can have physical, financial, emotional and organizational effects (Ventura-Madangeng & Wilson, 2009, p. 39). Despite Zero Tolerance and efforts to manage this problem, the problem of violence is escalating at an alarming rate (Ople et al., 2010, p. 21). Many nurses report being involved in or witnessing WV frequently. Up to 63% of WV incidents go unreported for reasons including not feeling that management will respond, worrying about punitive responses, or just feeling it is a normal part of the day (Ventura-Madangeng & Wilson, 2009, p. 38). Even the fact that there is not one accepted definition of WV may contribute to underreporting, and because of underreporting the true extent of the magnitude of the problem of WV exists (Ventura-Madangeng & Wilson, 2009, pp. 37-38). Seventy Five percent of ED nurses received no response to reports of violence according to Keefe (Keefe, 2011, p10).Work placeviolence can contribute to decreased productivity, absenteeism, high turnover rate, and many costs related to litigation and rehabilitation fees (Speedy, 2006, p. 243). Many nurses feel their workplace is not safe and work in an atmosphere of fear (Ople et al., 2010, p. 18). The more civil your workplace, the lower the rates of sick leave, fewer complaints to Equal Employment Opportunity commission, higher patient and employee satisfaction rates, standards will be met and patient care safer ("Bullying takes toll", 2010, p. 30). Workplace injuries from on the job violence cost organizations $202 billion dollars annually (Hoobler, 2006, p. 230).

Significance to Nursing

In one study an alarmingly 93% of the nurses felt that the hospital did not have policies to protect them (AbuAIRub, Khalia, & Habbib, 2007, p. 283). Physical layouts of many hospitals do not promote safety with visitors coming and going freely. Many times security is not a visible deterrent. Many employees are not trained in identifying or dealing with those who may become violent, nor are they trained in de-escalation.

The nursing profession has long endured the effects of WV. Although Joint Commission mandates “Zero Tolerance” and requires hospitals to have codes of conduct ("Bullying takes toll", 2010, p. 28), the problem continues. Nursing operates under conditions of great stress. Lateral violence and bullying are a daily occurrence for many. Nursing should take an active role in their hospitals, and also in the legislature to bring to the attention of those in higher authority the extent of the problem Nurses need to recognize that violence is not an acceptable part of their job. Reports should be filed whenever violence occurs and nurses need to demand a consequence for this behavior. Nurses need to educate themselves on workplace violence, its causes, effects, and solutions. Hospitals with no policy to address WV had 18.1% rate of violence, those with an effective zero-tolerance policy had a rate of 8.4 % (Keefe, 2011, p. 10).


A multi-faceted approach to develop an effective WV prevention plan is suggested by the following authors who are recognized, referenced and cited in this paper and credit will be given to each in the following solutions that are listed.

  1. Definition of the term WV in order to better research the problem. Recognition of the problem, causes, effects, and the most effective strategies to prevent WV.(Ventura-Madangeng & Wilson, 2009, p. 38)
  2. Zero tolerance for any WV from bullying to verbal aggression to physical violence. (Keefe, 2011, p. 10). Do not allow or ignore bullying or other abusive actions. WV cannot be tolerated: if organizations ignore and deny its presence; with the help of nurses, educators, the community and at the legislative level strategies must be develop and enforced to address this problem.
  3. Have a threat assessment completed to identify areas of improvement (Lewis & Contino, 2010, p. 1)
  4. Educate all staff on the recognition of potentially violent behavior, de-escalation techniques, and how to physically restrain patients (Keefe, 2011, p. 11).
  5. Reassess and monitor the responses to the strategy
  6. Involve community and legislative personnel in the process. Federal mandates for violence prevention, safety assessment, regular training, and prevention programs (Dickinson, 2009, p. 34-36).
  7. Institute measures to improve your physical layout of facility. (keypads, panic alarms, lighting) (Lewis, 2010, p. 1).
  8. Investigate underlying causal factors such as poor staffing, customer service skills, overcrowding, and inadequate staff training in dealing with violence. (Holmes, 2006)
  9. Develop a “code of conduct” which promotes civility respect, cooperation, conflict resolution, and antidiscrimination ("Bullying takes toll", 2010, p. 30). WV cannot be tolerated. Organizations cannot continue to ignore and deny the presence of WV. With the help of nurses, educators, community involvement and legislative action, strategies can be developed and enforced to address the problem of WV.

PICOT Format

Population of Focus: Abusive, Aggressive, or violent patients, family or coworkers in the hospital setting.

Intervention: Workplace Violence prevention strategies

Comparison: None

Outcome: Reduction in physical injuries, psychological effects, costs, improved climate which promotes quality patient care.

PICOT Question

In the hospital setting of abusive aggressive or violent family, patients or coworkers, will a WV prevention plan reduce the number of physical injuries, adverse psychological effects, reduce costs and improve the climate to improve quality patient care?

Rapid Appraisal of Evidence Based Research Articles Utilizing NRS441V Sample Format for Review of Literature(see Appendix A for continued resource appraisal).

AbuAIRub, R. F., Khalia, M. F., & Habbib, M. B. (2007). Workplace violence among Iraqi hospital nurses. Journal of Nursing Scholarship, 39(3), 281-288.

1. Summary of Article: This article investigated the occurrence and frequency of workplace violence (WV) among Iraqi nurses, the nurses’ responses to both the violence itself and the policies dealing with the violence and the violence prevention strategies (AbuAIRub, Khalia, & Habbib, 2007, p. 281).

2. Research Elements: Design, Methods, Population, Strength, Limitation: A descriptive exploratory survey was utilized interviewing 116 Iraqi nurses in a hospital setting in Bagdad City (AbuAIRub, Khalia, & Habbib, 2007, p. 283). A pilot study of 20 nurses was utilized who were then excluded from the study (AbuAIRub et al., 2007, p. 283). Modifications were done due to culturally sensitive topics in Iraq. (AbuAIRub et al., 2007, p. 283) The questionnaire was taken from several sources including the World Health Organization (AbuAIRub et al., 2007, p. 283) There were 5 sections to the questionnaire, 71 items were assessed with 3 open ended questions(AbuAIRub et al., 2007, p. 283). Consent, anonymity, and confidentiality were protected. A statistical package of social sciences (SPSS) version 14 was utilized to analyze the data. The sample size was small with over half being male participants. This was a unique study as violence in the hospital setting has not been explored previously. The data was collected over a short two month period of time in a war torn area of the world. The participants were chosen which could create a bias of the examiner potentially. The results are believable. This was definitely a necessary study. Not all 5 areas of the study were presented. Further data to be discussed in future manuscripts. This study was subject to the recall of the individual which may be skewed. This is also a war torn country where violence is seen to be an everyday occurrence so may be underreported.

3. Outcome(s): Research Results. The majority of participants reported that there were no procedures for reporting violent incidents in the workplace; 30.2% were worried about workplace violence; 91% had been exposed to workplace violence in the past year, 41% attacked physically, 14.3% with lethal weapons (AbuAIRub et al., 2007, p. 284). The effects on the nurse were described in a table. Most participants reported that no policies against workplace violence existed in their facility (AbuAIRub et al., 2007, p. 283).

4. Significance to Nursing and Patient Care: This study presented the psychological effects of violence to the nurses, along with the injuries and stressors a nurse must work under. It defined a clear need for federal legislation and hospital support to protect healthcare workers, prevention strategies such as limiting access to hospital, security, and education programs, War conditions and major stressors contribute to violence and other countries can take precautions to recognize and plan for violence prevention. Violence in a hospital setting does not contribute to quality of care and can result in injuries, and job dissatisfaction, which all will eventually affect patient care (AbuAIRub et al., 2007, p. 287).

Bullying takes toll on HCWs and patients: Joint Commission: Zero Tolerance for intimidation. (2010, March). Hospital Employee Health, (March), 28-30.

1. Summary of Article: The more that workplace bullying is allowed, the worse the condition is and this affects staff and patients alike ("Bullying takes toll", 2010, p. 28).

2. Research Elements: Design, Methods, Population, Strength, Limitation: Article noted effects of bullying on patients and staff. A pilot study to institute CREW (Civility, Respect and Engagement in the Workplace) a program to promote civility in the workplace noted. Lower Equal Employment Opportunity Commission complaints, higher employee and patient satisfaction noted with high levels of civility ("Bullying takes toll", 2010, p. 30).

3. Outcome(s): Research Results Workplaces that permit intimidation and bullying have lower satisfaction ratings, poorer patient care, and injuries ("Bullying takes toll", 2010, p. 28). Injury, illness and assault are higher in workplaces that allow workplace harassment ("Bullying takes toll", 2010, p. 28). Ten to fourteen percent of workers noted bullying ("Bullying takes toll", 2010, p. 29).

4. Significance to Nursing and Patient Care: Joint Commission requires a zero tolerance for bullying, and nurses and other coworkers must ensure that this is upheld ("Bullying takes toll", 2010, p. 29). Assisting in your own practice to improve the civility in your culture is important ("Bullying takes toll", 2010, p. 30).

Chapman, R., Styles, I., Perry, L., & Combs, S. (2010). Examining the characteristics of workplace violence in one non-tertiary hospital. Journal of Clinical Nursing, 19, 479- 488.

1. Summary of Article: To examine the prevalence and characteristics of WV and investigate reasons for not reporting incidents.

2. Research Elements: Design, Methods, Population, Strengths, Limitations: This quantitative, qualitative survey was distributed to 332 nurses in a Western Australia non-tertiary hospital (Chapman, Styles, Perry, & Combs, 2010, p. 479). Only 113 nurses participated in the study over a 12 month period (Chapman et al., 2010, p. 479). This type of study has not been done previously in Australia and so there is no data to compare findings to see if reflective of other studies (Chapman et al., 2010, p. 479). The nurses that did respond may have been biased in their views of violence as they did volunteer for study. The study of a non tertiary hospital in the private sector generally has less incidence of violence than a public hospital (Chapman, Styles, Perry, & Combs, 2010, p. 480). Consent for study obtained, an initial testing of instrument done by 12 nurses was completed. Fifty nine questions were asked with 18 being open ended so a great deal of data was obtained. SSPS version 15 utilized to analyze data. Organizations are obligated to provide a safe environment, and this article points to the need for education and changes in policy. Quantitative portion was not random, so bias could occur. This was retrospective so participants recall could be inaccurate. Study seems reliable and necessary. Tables were utilized to show data results.

3. Outcome(s): Research Results: Of the 113 participants, 75 % reported workplace violence in the past year of study (Chapman et al., 2010, p. 482). Violence defined as verbal abuse threats and assault (Chapman et al., 2010, p. 482). Weapons such as knives guns and hospital equipment were utilized as often as noted 3% weekly of respondents (Chapman et al., 2010, p. 484). Only 16 % filled out an occurrence report; 50% reported this to a supervisor (Chapman et al., 2010, p. 484). Reasons not to report were that the nurses considered violence to be a part of the job and they perceived management would not be responsive to the report, and the nurse might be punished (Chapman et al., 2010, p. 484). Only 16% of WV incidents had been reported (Chapman et al., 2010, p. 485)

4. Significance to Nursing and Patient Care: It is significant that nurses consider workplace violence to be a part of the job. The occurrence of WV is probably greater than what any statistics can reveal due factors which keep nurse from reporting WV incidents (Chapman et al., 2010, p. 481). If nurses do not bring WV’s occurrence to the attention of the legislature or to their superiors, the problem will continue to escalate and nurses will continue to experience WV. This will ultimately affect patient care critically causing nurses to leave the profession and worsen the nursing shortage (Chapman et al., 2010, p. 481). Nurses must not allow themselves to become victims but push for prevention strategies to reduce this serious trend. Organizations are obligated to provide a safe environment, and this article points to the need for education and changes in policy.

Cleary, M., Hunt, G., Walter, G., & Robertson, M. (2009). Dealing with bullying in the workplace: Toward zero tolerance. Journal of Psychological Nursing, 47(12) , 34-:41.

1. Summary of Article: This article focused on the effects of a form of WV called bullying. The effects of bullying can cause disruptions in the harmonious working of a unit and compromise the care and safety of patients (Cleary, Hunt, Walter, & Robertson, 2009, p. 35). Zero tolerance for bullying and harassment of nurses by patients or other staff must be adopted.

2. Research Elements: Design, Methods, Population, Strengths, Limitations: This article provided statistics that were cited and referenced regarding the occurrence and effects of bullying. There was variance in the percentage of bullying reported in three studies which varied from 27% to 46% of reports of recent bullying. Bullying may result in psychological or physical harm. Bullying according to the article was “widespread “despite zero tolerance (Cleary et al., 2009, p. 35).

3. Outcome(s): Research Results: Bullying is widespread and can result in poorer outcomes for patient care (Cleary et al., 2009, p. 35). Bullying should not be tolerated and several suggestions for treatment of bullies included keeping documentation of events, not allowing victimhood to occur, organizations creating an environment of caring and creating polices supportive of this goal (Cleary et al., 2009, p. 40). Failure of organizations to champion this goal by policies, dealing with bullies through counseling or termination, will ultimately affect the consumer, the organization and the profession (Cleary et al., 2009, p. 40). Article results were valid and consistent with other literature sources that were read.