Running head: SAFETY AND PROTECTION FOR NURSES 1

Safety and Protection Strategies for Nurses in the Workplace

Denise Preston

Ferris State University

SAFETY AND PROTECTION FOR NURSES 2

Abstract

This paper describes the need, and plan, for improved safety measures in the healthcare

environment. Risk factors specific to the healthcare area are discussed including the results of

surveys and research to support the need for improvements. The resulting negative effects of

violence against the healthcare staff, and further results on the facility are addressed. The safety

plan itself is detailed with, different aspects of the strategy noted. The crucial aspect of the plan,

which is, educating each staff member individually in the area of self-defense, recognizing and

mitigating emotionally escalating situations, is highlighted. The reasoning behind the two fold

approach to education discussed. With implementing the changes of education and environment,

the need for organizational reliability and quality improvement model is described as a

successful way to create a positive change in safety. In making these changes, the facility leaders

are recognized, to have an ethical responsibility, to ensure the safety of personnel, in the facility

(Donnellan, 2014). The intended results are, a healthcare facility where staff, patients, and the

community will be able to work, and seek services without concern of harm.

Keywords: workplace violence, assault, safety

SAFETY AND PROTECTION FOR NURSES 3

Protective Strategies for Nurses in the Workplace

The purpose of this paper is to spotlight the frequency and serious consequences of

workplace violence in the healthcare setting. This is an escalating issue for healthcare staff, and

an ethical responsibility for administrators, and leaders to address in the facility. The problem

requires a thorough investigation into the necessary methods required, to curtail the violence.

The need is staggering in healthcare, and compels a solution. See Appendix A.

Need for Safety Measures in Healthcare

The National Institute for Occupational Safety and Health, (NIOSH), has defined

workplace violence in the hospital, from patients, and their families, as being either threatening,

or physical assaults. These can range from verbal threats, to beating or even use of weapons

(CDC, 2002). Of all assaults in the workplace, 70-74% occurs in healthcare, and social services

(Winnett, 2015). In the last decade, there has been a 110% increase in reported violence against

healthcare workers. According to a survey, up to 25% of nurses have been a victim of violence

(Fernandez-Campbell, 2016). This disparity in workplace violence is due to many factors.

Many hospital workers treat trauma patients, who are victims of violence (Barlow, 1997), who,

also, have the potential of being violent, or of drawing violent people into the hospital. Other

factors that increase risk are, patients with mental health disorders, or drug and alcohol problems,

patient and families with highly emotional situations (Gillespie, 2010)). Environmental factors

are, design, and lighting, patient throughput, appropriate staffing, inadequate security, lack of

safety plans, policies, and staff training (Loyola, 2017).

Part of the continuing high rate of violence in healthcare is due to, administration

response to the reporting workers. Some are told to accept this behavior as a part of the job, this

alone could represent up to 20% of victims (Fernandez-Campbell, 2016). Some were told
SAFETY AND PROTECTION FOR NURSES 4

tolerate it, because of the dollar amount each offender represents (Gates, 2004). For some, the

expectation at work is that you are to return to your post, after an assault (Gates, D, 2011).

The results of the violence are devastating. It affects not only the victim, but, the workers

around them, other patients, leaders, and the entire facility. Up to 17% of nurses have

characteristics of Post-Traumatic Stress Disorder (PTSD), such as, loss of sleep, nightmares,

flashbacks, anger, anxiety, and helplessness (Gates, 2011). The psychological suffering is on top

of the physical injuries, such as, bruises, cuts, scars, broken bones, bites, and disabilities (CDC,

2002). The outcomes to the facility are many, including, high job turnover, security increase,

absenteeism, medical costs, decreased morale, and decrease in patient satisfaction (Gates, 2011).

These things add up to a toxic environment at work, revenue loss due to staff replacement, and

non-payment by the insurance payers due to inferior quality of care. Thus, there is a need for

increased safety policies, procedures, and measures, to keep standards high for our communities.

Ethical Implications to Nursing

Hospital and nurse leaders, while being conscious of the facility mission and values,

must ensure the safety of nurses, as an ethical responsibility (Donnellan, 2014). Research by the

National Institute for Occupational Safety and Health (NIOSH), a research division of the

Centers for Disease Control and Prevention (CDC), confirms this recommendation with its

studies (NIOSH, 2002). Occupational Safety and Health Administration (OSHA) affirms this

stance, by advising that healthcare providers implement violence prevention through a five prong

program (Winnett, 2015). Nurses, other staff and the community, should expect an environment

as free from harm as possible, and for the leadership to monitor situations, and issues in the

facility for effectiveness, and safety from violence (Donnellan, 2014), with a zero-tolerance

policy in place (OSHA, 2012). The work environment that is unsafe is dangerous to the staff,

patients, and families. It is not an environment where quality care can be given. An unsafe
SAFETY AND PROTECTION FOR NURSES 5

environment produces a dissatisfied and anxious caregiver (Gates D. , 2004) . This equals

substandard care, and in the end, it is detrimental to quality care, and the facility.

While creating policies regarding safety, there are many ethical dilemmas that arise

regarding the practices that are implemented to maintain safety. Some security measures may

seem invasive, or morally inappropriate. As an example, some may disagree with cameras to

monitor violent patients, or public areas in the facility, or object to security guards in patient

areas. These efforts must be carried out with respect, and confidentiality. Transparency,

regarding the approaches, and reasoning behind them should be an open-ended educational

conversation between employees, and patients, and the community (Donnellan, 2014).

The policies, and safety measures should be established by committees, that include

leadership, and the frontline employees. This is to ensure compliance with facility values and,

fair, but, effective practices. This team should also be available to mediate, and recommend,

should conflict arise, that involves the policies, and measures (Donnellan, 2014). The team, and

policies they advocate should remain adaptive to the ever changing healthcare environment.

Plan for Safety from Violence

Just as violence against nurses has reached epidemic proportions, Press+Ganey has

announced, a new nursing-sensitive quality indicator for Assaults on Nursing Personnel. The

new indicator will support nurse safety with data, and comparisons, to assess the situation

(Press+Ganey, 2017). Along with the other nursing sensitive indicators (NSI) for environment

and safety, the measuring stick for nursing safety will be enhanced.

This NSI will pave the way for, a risk assessment of the facility, by an interdisciplinary

committee. This committee would survey employees for safety concerns, and combine the

information with local law enforcement, to get a good measurement of the safety standing of the

facility (The Joint Commission, 2017). The committee will then report results to administration,
SAFETY AND PROTECTION FOR NURSES 6

after assessing the facilitys situation. A zero tolerance for violence will be established, a policy

put in place, and action steps to reduce the environmental risk factors (ALICE, 2015). Policies

should include, the reporting, documenting, monitoring and debriefing of violent accounts and

near misses (Winnett, 2015). This will promote the continual evaluation of the risk situation, so

changes can be made as needed. Leaders in security, staffing, throughput and environment will

need to evaluate, and improve the inadequacies in their areas, as deemed necessary by the risk

assessment committee. This will result in a better hospital wide safety improvement.

One main, and specific area for needed improvement, is at the point where the violence

occurs, and at the exact time it occurs. Personal training for each staff member is needed.

Employees are at greater risk for workplace violence, if they have not received appropriate

training (Gillespie, 2010). Violence can be mitigated, or possibly even avoided through

preparation (OSHA, 2004). Training must be two fold. First, staff must be trained to recognize

the psychological aspects of a potential situation. Staff needs to be aware of surroundings, and

not to dismiss actions, such as, anger or threatening body language, or mind altering substances

in the patient. Learning to maintain anger diffusing behavior is also beneficial (Winnett, 2015),

by presenting a calm and caring attitude, and acknowledging the patients needs, or perceived

needs. Close proximity to the patient should be avoided, or using a raised voice to the patient,

and knowing it is perfectly correct to leave the situation and call security (CDC, 2002). If,

leaving the situation is not an option at the time, then self-defense, as the second part of the

training, could be an effective strategy until help arrives or escape is possible (Gillespie, 2010).

Self-defense training would, not only take the safety of the staff member in to account, but the

safety of the patient, family members, and other staff.

SAFETY AND PROTECTION FOR NURSES 7

This plan of self-defense training would be made available to all new staff through the

education department, during their orientation period. Employees already on staff would be able

to sign up for the class. It would be carried out in a classroom situation, to educate on the

psychology of an assault, and the reasoning behind the measures taken. The education would

also have a physical aspect that would use acting out scenarios, and responses to them. Practicing

in this way, the employee would become less anxious about the possible situation, because they

will have a plan.

With Safety, Comes, Higher Standards

The organization must make reaching improvement goals a priority (Studer Group,

2017). Increasing the safety of an organization, doesnt just mean environmental improvements,

and making policy changes. It means that the organization, when making the changes, must also

be consistent and reliable in following through with their plans and policies (Gamble, 2013).

Being reliable is facilitated easier, when leaders have a plan to collect, and use data. Then, test

any changes, by having a Quality and Improvement model. The model is a framework for

efficiency, and success, by providing not only a guide for change, but, communicating the

change, and then re-evaluating, as the system directs (AAFP, 2017). See Appendix B.

To make changes, that the organization can reliably adhere to, the interdisciplinary

committee needs be experts in their areas. They must work in a structured framework. They are

charged with finding root causes of the unwanted outcome. Then, come up with a feasible plan to

halt those outcomes, by collaborating, and coordinating with themselves, and other experts to

find solutions (Studer Group, 2017). This requires effective communication.

Implementation and communication of solutions, can best take place in a, Just Culture.

This culture does not focus on punishing individuals for reporting errors. It takes the information,
SAFETY AND PROTECTION FOR NURSES 8

compiles it with other data, to find solutions. The outcome will be, increased data collection, and

better evaluations of outcomes. Staff will not be concerned of blame placed on them, for a less

than favorable outcome to one of the new plans, so, communication is open and better evaluated

(ANA, 2010).

Summary

Healthcare workers, and especially nurses, have the possibility of encountering

workplace violence at an alarming rate. Statistics show, that the trend is not decreasing, but, is

increasing. The results of this violence is devastating, not only to the victim, but, to the facility,

and other employees as well. It causes decrease in job satisfaction, which can result in high

employee turnovers or lower quality of work. Either way, the hospital loses quality in culture,

and care, which results, in lower or non-payment by insurers. In this regard, the hospital

administrators have an ethical obligation to provide as safe a facility as possible. The safety

measures implemented must be in line with the facility ethical standards.

The plan to remedy this situation is to form an interdisciplinary committee to investigate

needs, and form plans. Part of the plan is to educate the staff in self-defense. The education

would be classroom, and scenario, with the goal of teaching the psychological aspect, as well as

practical physical tactics to prevent, mitigate or avoid violence. These plans would be

implemented, and the results studied. The plans would be communicated to staff, and put in to

effect. Then, for the future, they would continue to gather data on safety, to see if any more

changes are indicated.

The plan, to curtail the violence experienced by our healthcare workers is an important

one. It is a step to better quality care. It is essential to all our wellbeing, to have high quality

healthcare in our communities.

SAFETY AND PROTECTION FOR NURSES 9

Appendix A

Non-Fatal Assaults per 10,000

30

25

20
Nursing

15 Soc.Serv.
Overall

10 Private

0
Private Overall Soc.Serv. Nursing

This chart represents the incidence of non-fatal assaults per 10,000 in the following categories;

Private sector industry, Overall health services, Social Services, and Nursing and personal care

Facilities (OSHA, 2004).

 SAFETY AND PROTECTION FOR NURSES 10

Appendix B

Model of Quality Improvement for Safety

Plan: Risk
Communicate plan to Assessment
facility and re-evaluate as
needed.

Improve
Make changes
and Impart Safety and Educate Staff
and Improve
permanent
Plan Protection Environment

of Staff

Study Results
of
Improvement
Data

This model depicts the cyclical Plan-Do-Study-Act Model for Improvement.

SAFETY AND PROTECTION FOR NURSES 11

References

10 ways to prevent workplace violence. (2015). Retrieved from ALICE training institute:

www.alicetraining.com/resources-posts/blog/10-ways-to-prevent-workplace-violence

Barlow, C. a. (1997). Violence against surgical residents. Armstrong Laboratory, logistics

research division, 74-78.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1304429/pdf/westjmed00336-0010.pdf

Basics of quality improvement. (2017). American academy of family physicians (AAFP).

www.aafp.org/practice-management/improvement/basics.html

Donnellan, J. (2014). The ethics of hospital security. Healcare executive, 58-61.

https://www.ncbi.nlm.nih.gov/m/pubmed/24938007/

Fernandez-Campbell, A. (2016). Why violence against nurses has spiked in the last decade.

www.theatlantic.com/business/archive/2016/12/violennce-against-nurses/509309

Gamble, M. (2013). 5 traits of high reliability organizations: how to hardwire each in your

organization. Becker's Hospital Review.

https://www.beckershospitalreview.com/hospital-management-administration/5-traits-

of-high-reliability-organizations-how-to-hardwire-each-in-your-organization.html

Gates, D. (2004). The epidemic of violence against healthcare workers. Occupational

Environment med, 649-50.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1740822/pdf/v061p00649.pdf

Gates, D. G. (2011, March-april). Violence against nurses and its impact on stress and

productivity. Nursing economics, pp. 59-66.

https://www.ncbi.nlm.nih.gov/pubmed/21667672
SAFETY AND PROTECTION FOR NURSES 12

Gillespie, G. G. (2010). Workplace violence in healthcare settings: risk factors and protective

strategies. Rehabilitation nurse, 174-84.

http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.942.4217&rep=rep1&type=pdf

Studer group(2017, March). High reliability iin healthcare: creating the culture and mindset for

patient safety. Canadian college of health leaders healthcare management forum.

https://www.studergroup.com/resources/articles-and-industry-updates/articles-and-

whitepapers/high-reliability-healthcare-creating-the-culture

Hospitals can prevent workplace violence. (2017). Retrieved from Loyola online:

www.elearning.loyno.edu/dnp-programs/resource/hospitals-prevent-workplace-

violence

Just Culture. (2010). Retrieved from ANA: http://nursingworld.org/psjustculture

Press ganey introduces first quality indicator to measure assaults on nursing personnel. (2017).

www.pressganey.com/about/news/new-ndnqi- enables-hositals-to--measure-assess-and-

improve

Preventing workplace violence for health care & social service workers. (2004). Retrieved from

OSHA: www.osha.gov/Publications/osha3148.pdf

Quick safety-issue five. (2017). Retrieved from The Joint Commission:

www.jointcommission.org/issues/article.aspx?article=kPXQxso3Rvfy4zxRHf0Tbsma

Violence occupational hazards in hospital. (2002). Retrieved from CDC:

www.cdc.gov/niosh/docs/2002-101

Winnett, N. (2015). OSHA issues new guidelines on workplace violence prevention for

healthcare. Retrieved from OSHA law blog:

www.oshalawblog.com/2015/04/articles/osha-issues-new-guidelines-on-workplace-

violence-prevention
SAFETY AND PROTECTION FOR NURSES 13

Workplace violence. (2012). Retrieved from OSHA:

www.osha.gov/SLTC/healthcarefacilities/violence.html