Issues in Mental Health Nursing, 31:89–95, 2010Copyright © Informa Healthcare USA, Inc.ISSN: 0161-2840 print / 1096-4673 onlineDOI: 10.3109/01612840903267638

Violence Against Women: The Phenomenon of WorkplaceViolence Against Nurses

R. J. Howerton Child, RN, MSN and Janet C. Mentes, PhD, APRN, BC, FGSAUniversity of California—Los Angeles, School of Nursing, Los Angeles, California, USA

Registered nurses have been the recipients of an alarming in-crease in workplace violence (WPV). Emergency and psychiatricnurses have been found to be the most vulnerable and yet few solidreporting procedures exist to fully account for a true number of in-cidents. Further compounding the problem is the lack of a standarddefinition of violence to guide reporting procedures, interventions,legislation, and research. While there are certain risk factors thatnot only predispose the nurse and the patient to WPV, researchcontinues to attempt to parse out which risk factors are the keydeterminants of WPV and also which interventions prove to be sig-nificant in reducing WPV. The nursing shortage is expected onlyto increase; recruitment and retention of qualified staff membersmay be deterred by WPV. This necessitates focused research on thephenomenon of workplace violence in health care.

Violence is acknowledged by the World Health Organization(2002) as a major global public health issue, with the UnitedStates perceived as more violent than any other industrializednation (Mattaini, Twyman, Chin, & Lee, 1996). Since societalviolence trickles into all aspects of society, it is not surpris-ing that violence in health care settings is increasing. Whilecertain occupations are acknowledged by society to have in-herently dangerous facets—police and military occupations forexample, the health care environment is generally not includedin this cadre of violent settings and nurses are not acknowl-edged as the recipients of such violence (Kowalenko, Walters,Khare, & Compton, 2005). Although the under-reporting ofwork place violence (WPV) limits full understanding of theextent of this problem, in health care settings nurses have thehighest rate of violent attacks out of all health care workers(Anderson, 2002; Peek-Asa Cubbin, & Hubbell, 2002). The USDepartment of Labor (2002) reported that WPV is the thirdleading cause of all occupational deaths and the second lead-ing cause of occupational deaths in women. Fatal workplaceinjuries are only one part of the problem; according to the USBureau of Labor Statistics (BLS), nurses have a nonfatal assault

Address correspondence to R. J. Howerton Child, University ofCalifornia, School of Nursing, 700 Tiverton Ave., Factor Building, LosAngeles, CA 90095. E-mail: rjahy@yahoo.com

rate of 31.1 per 10,000 as compared to the private occupationalsector as a whole which has 2.8 nonfatal assaults per 10,000(Trinkoff et al., 2008). Given these statistics, it is not surprisingthat an overwhelming 80% of nurses do not feel safe in theirworkplace (Peek-Asa, et al., 2009) and 25% of surveyed psy-chiatric nurses suffered disabling injuries from patient assaults(Quanbeck, 2006).

Nurses in the emergency department (ED) are at increasedrisk for WPV. A survey of 221 North American hospitals re-vealed that the ED was the most common place in the hos-pital for WPV. One hundred seventy ED directors reported atleast one physical assault per month and 32% reported at leastone verbal threat per day (Kowalenko et al., 2005). Mahoney’s(1991) survey of approximately 1200 Pennsylvania emergencynurses further supports the widespread prevalence of WPV inthat setting. She reported that 97.7% of nurses reported experi-encing some form of violence during their nursing careers with60% stating that the violent experience adversely affected theirwork performance. The many reports of WPV in EDs tend toreinforce the perception that violence is a part of the job, as as-sault and verbal abuse routinely occurs in these settings (Lewis,Dickinson, & Contino, 2007).

Because violence is less expected in the health care settingand, when it does occur, is seen as a part of the job, the phe-nomenon of workplace violence (WPV) directed toward nursesis inadequately documented, under-reported, and poorly man-aged when it is reported. This article presents what is knownabout WPV against nurses including the definition, risk fac-tors, and consequences of WPV. It also reviews and critquesthe literature on programs to prevent or decrease incidences ofWPV.

DEFINITION OF WORKPLACE VIOLENCEThere is no accepted standard definition of workplace vi-

olence. Luck, Jackson, and Usher (2007a) and Fernandes etal. (1999) assert that these variations in definitions compoundthe problem of addressing the issue of WPV towards nurses,where violence can range from verbal abuse to serious in-jury. Hughes (2006) acknowledges that WPV is a multifaceted

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90 R. J. HOWERTON CHILD AND J. C. MENTES

phenomena and that the lack of a common definition andlanguage to describe WPV is an obstacle that hampers thenurse from being able to predict and appropriately man-age WPV. Multiple studies parse out the definition of vi-olence into physical versus nonphysical violence (Catlette,2005; Gallant-Roman, 2008a; Gates, Ross, & McQueen, 2005;Hampton, 2007; Mayhew & Chappell, 2002; Phillips, 2007);with other investigators broadening the definition to includeforms of harassment (Findorff, McGovern, Wall, & Gerberich,2005; Pawlin, 2008; Ray, 2007; Whelan, 2008). Further, theterm aggression is often used interchangeably with violence andhas been defined as “overt behavior involving intent to inflictnoxious stimulation or behave destructively towards another or-ganism” (Quanbeck, 2006, p.744). Legal definitions are morespecific and limited to the threat of or actual physical violence,for example, the State of California’s definition of assault is,“an unlawful attempt, coupled with a present ability, to commita violent injury on the person of another” (Ray, 2007, p. 230).

Mayhew and Chappell (2002) describe three categories of vi-olence that occur across worksites: internal, external, and clientinitiated. Internal violence occurs between employees of an or-ganization, external violence is perpetrated by strangers outsideof the organization (e.g., the robbery of a convenience store),and client initiated violence occurs between workers and cus-tomers or clients, such as workplace violence in the health caresetting (Mayhew & Chappell, 2002). Although all three cate-gories of violence may occur in the health care setting, clientinitiated violence is the most frequent.

CONSEQUENCES OF WPVThe consequences of WPV are costly from a fiscal as well as

patient care perspective. In 2001, the Bureau of Justice Statisticsestimated that WPV cost $4.2 billion annually and was rising(Gallant-Roman, 2008a). The cost per incident is an estimated$250,000 in terms of lost time and legal fees (Morrison & Love,2003). Jansen, Dassen, and Jebbink (2005) found that 4% ofemergency department nurses had one or more sick day peryear due to an assault in the workplace. In addition to the costto health care institutions and society, patient care and nursingretention are affected as well. For example, WPV leads to de-creased quality of patient care, low staff morale, and increasedstaff absenteeism (Hampton, 2007). ED nurses reported beingunable to work in the ED again after a violent incident, andincreased “burn-out” or compassion fatigue (Gates et al., 2005;Hampton, 2007; Lewis et al., 2007; Luck, Jackson, & Usher,2007b; Phillips, 2007). Assaulted staff members have higherrates of substance abuse, posttraumatic stress disorder (PTSD),and other anxiety disorders (Quanbeck, 2006).

Physical assault certainly can have obvious outward manifes-tations but the literature increasingly demonstrates that verbalassault has even more negative and long lasting ramifications.Nachreiner et al. (2007) states that RNs and LPNs were morelikely to need treatment for non-physical assaults and that these

staff reported more feelings of frustration, anger, stress, fear,and anxiety due to verbal assault. Long term stress and traumais often cumulative and leads to nurse apathy, flashbacks, cryingspells, intrusive thoughts, and nightmares (Phillips, 2007). Kam-chuchat et al. (2008) found that nurses reported psychologicalimplications related to WPV, including poor relationships withcolleagues and family members. Other adverse effects that occurin the long term trajectory of WPV include negative effects onrecruitment and retention on nurses, decreased productivity andefficiency and fewer resources for workers, possibly related toincreased worker’s compensation claims and the need to recruitand train new nurses (Fernandes et al., 1999; Hampton, 2007;Luck et al., 2007b).

RISK FACTORSMultiple risk factors have been cited for the increase in WPV

in hospital settings, including interacting factors related to pa-tient and family, nurse, and the environmental setting. Addi-tionally the attitudes of patients, nurses, and administrators canimpact on WPV. The APNA (2008) cites exposure and desen-sitization to violence in society as a whole as contributing toWPV in health care.

Patient and family factors that lead to an increased likelihoodof violence against health care workers can include: (1) acutedisease states, such as alcohol or drug intoxication, self-injuriousbehavior, or a current exacerbation of a psychiatric illness (Bow-ers, Allan, Simpson, Nimjan, & Warren, 2007; Crilly, Chaboyer,& Creedy, 2004; Luck, Jackson, & Usher, 2007a); (2) Height-ened states of emotion in patients or their families that includeanxiety, fear, hopelessness, grief, frustration, or loss of control(Fernandes et al., 1999; Kowalenko et al., 2005; Luck et al.,2007a, 2007b); (3) Specific personal characteristics includinggender—men are more likely to perpetrate both physical andverbal violence than women (Bowers et al., 2007; Nachreineret al., 2007; Quanbeck, 2006;); and (4) Serial perpetrators, whoaccording to Quanbeck (2006) and Lipscomb et al. (2006), areless than 10% of the population, but who are responsible for50% of the violence committed in the workplace setting.

Nursing and staff risk factors include age, gender, nursing ex-perience, and a history of a current or past abusive relationship(Anderson, 2002; Catlette, 2005; Duncan et al., 2001; Gallant-Roman, 2008b; Jackson, Clare, & Mannix, 2002; Kamchuchatet al., 2008; Tang, Chen, Zhang, & Wang, 2007). Nurses whoare younger and have less experience have been found to haveincreased rates of WPV however, this may be due to the fact thatolder and more experienced nurses may be in management po-sitions and have less patient contact (Anderson & Parish, 2003;Catlette, 2005; Duncan et al., 2001; Gallant-Roman, 2008b;Kamchuchat et al., 2008; Little, 1999; Tang et al., 2007). Ander-son and Parish (2003) found that male nurses were more likely tobe assaulted than female nurses but this refers to the psychiatricsetting only. Other studies report that females are more likelyto be assaulted in the workplace, however the predominance of

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women in the profession make this finding obvious (Findorffet al., 2005; Kamchuchat et al., 2008).

Environmental factors include specific settings where acutelyill patients tend to be treated, such as EDs and psychiatric set-tings, which have the highest incidences of WPV (Deans, 2004;Duncan et al., 2001; Fernandes et al., 1999; Gallant-Roman,2008a; Gates et al., 2005; Lenehan, 2005; Peek-Asa et al., 2007;Tang et al., 2007). Risk factors inherent to the environment ofthe ED include easy accessibility; 24-hour access; increasednoise and, therefore, perceived chaos by patients; high stress;decreased security; and long waiting times (Crilly et al., 2004;Fernandes et al., 1999; Luck et al., 2007a, 2007b; Phillips, 2007;Trinkoff et al., 2008). When decreased staffing leads to nursesworking alone or during later shifts, WPV tends to increase(Gallant-Roman, 2008a; Tang et al., 2007).

Attitudes of patients and administrators serve as interactingrisk factors for WPV. Patients’ attitudes about the caregiving sit-uation may contribute to the likelihood of WPV against nurses,specifically when patients and their families perceive that theirneeds are not being met. Over 1000 violent acts investigated byQuanbeck (2006) were triggered by either a patient request thatwas refused or a directive to the patient to alter their behavior.Attitudes of administrators also contribute to WPV, when theattitude that such events should be tolerated as part of the job isthe norm (Trinkoff et al., 2008). Morrison and Love (2003) alsoassert that administrators may fail to act in incidents of WPVfor fear of liability.

NURSES’ PERCEPTIONS OF WPVA landmark study of Minnesota nurses (as cited by Gallant-

Roman, 2008a) found that 27% of nurses thought WPV wasa problem in their facility but only 52% thought WPV waspreventable. May and Grubbs (2002) found that nurses wereconcerned about their safety 91% of the time but felt that theirinstitutions of employment only took protective measures 41%of the time.

The intent of the perpetrator of WPV was also a factor innurses’ perception of the type of violence. Nurses who werebitten or hit by a confused or demented patient did not classifythe assault as WPV because of a perceived “lack of intent”(Ferns, 2006, p. 43). Fern (2006) argues the point that, regardlessof intent, the nurse is still injured. Some nurses also feel thattheir actions contributed to the violent event or were even thecause of the event (Deans, 2004; Ferns, 2006; Luck et al., 2007b)and thus will be less likely to report the incident. This victimblaming has been supported by hospital administrators for years,which continues to encourage the silent epidemic of WPV.

Numerous studies refer to the accepted attitude that WPV is“part of the job” for nurses (Deans, 2004; Jansen et al., 2005;Luck et al., 2007b; Phillips, 2007; Ray, 2007; Whelan, 2008;Wiley, 2008) and comes “with the territory” (Alexander, 2001).Zeinecke and Sharpe (1998, cited in Jansen et al., 2005) statedthat over 50% of RNs in hospitals were injured in WPV events

and accepted it as a routine occupational hazard. Whittington(2002) found that staff members with greater than 15 yearsexperience are more tolerant of WPV but also scored higher onthe Maslach Burnout Inventory- Human Services Survey.

REPORTING AND UNDER-REPORTINGThe lack of a standard definition for WPV, as well as spe-

cific nurse and institutional attitudes about WPV, contribute tounder-reporting of these events. Findorff et al. (2005) assertthat accurate and consistent reporting of WPV is important toprevent future events of WPV. Consistent reporting would assiststaff and administrators in ascertaining efficacious interventionsto prevent future violent events by examining contributors tocurrent violent events. Accurate statistics are difficult due tothe under-reporting of WPV (Gallant-Roman, 2008a). Findorffet al. (2005) define under-reporting as when “an individual isvictimized and does not report the event to an employer, police,or through other means” (p. 399). Under-reporting or failure toreport also may lead to long term stress and posttraumatic stressdisorder and interfere with successful worker’s compensationclaims (Doherty, 2007; Lewis et al., 2007).

Reporting of WPV was found to be increased if the victimwas male, if the perpetrator was a non-patient (visitor, familymember, etc.), and if the level of violence experienced was sig-nificantly physical and violent (Findorff et al., 2005). Pawlin(2008) found that other barriers to reporting included the possi-ble condition that staff was inured to violence, reporting proce-dures were inconvenient, and the perception that nothing will bedone with the report (Gallant-Roman, 2008a; Gates et al., 2005;Mayhew & Chappell, 2002). Numerous other studies reporteda perceived lack of action by those who are charged with tak-ing action based on the report (Ferns, 2006; Gates et al., 2005;Hampton, 2007; Pawlin, 2008; Phillips, 2007).

Nurses do not report WPV because they feel that they will beviewed as incompetent, as having provoked the incident, or astrouble makers because of lack of physical injury (Ferns, 2005;Pawlin, 2008; Phillips, 2007; Ray, 2007). Other possible theoriesfor why nurses do not report WPV include that nurses have littleknowledge about existing reporting procedures, feel they wouldbe “judging” the patient (this being counterintuitive to nursing),the numbing of the nurse victim due to societal exposures and thesocialization of genders (i.e., females are expected to use morecovert measures to respond to violence, not initiate violence orbe a “whistle blower”) (Ferns, 2006; Hampton, 2007; Luck etal., 2007b; Pawlin, 2008; Phillips, 2007).

Reporting of WPV is poor and yet it is necessary to correctlyidentify the scope of the problem and subsequently inform hos-pital administration and society at large (Crilly et al., 2004; Fer-nandes et al., 1999). Some attempts to increase reporting andthe safety of the work place include environmental changes,“violence logs,” and national reporting systems (Armstrong,2002; Hampton, 2007). A violence log is a singular data basethat details violent events in chronological order to better keep

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consistent recordings of these types of incidents. Oregon hasrecently implemented a program for tracking violent events byinitiating the Workplace Violence Prevention Law for Health-care. As of January, 2009, hospitals in Oregon must report WPVdata to help better audit and analyze all assaults to aid in furtherpreventative efforts (Oregon Nurses Association, 2009).

LEGAL RAMIFICATIONSWPV has resulted in legislation due to the high financial and

human costs associated with these events. The first case of crim-inal prosecution of inpatient assault occurred in 1978; howeverit has only been recently—in the late 1990s, early 2000s, thatlegislation regarding WPV has come to the forefront (Quan-beck, 2006). California, Colorado, Iowa, Illinois, Pennsylvania,South Carolina, Massachusetts, and New York all have increasedpenalties for assaults against nurses (Wiley, 2008). There is notsufficient research, however, to ascertain whether or not thesepenalties are enforced. California was the first state to enactlegislation, California Hospital and Security Act Assembly Bill508, which required acute care and psychiatric facilities to im-plement comprehensive WPV prevention programs (Luck et al.,2007b; Peek-Asa et al., 2007). The National Institute for Occu-pational Safety and Health (NIOSH), in 1996, published a listof risk factors for WPV (Ray, 2007). The 1996 OccupationalSafety and Health Administration (OSHA) guidelines for pre-venting WPV for Health Care and Social Workers included ageneral duty clause that states that employers have a “generalduty to provide their employees with a workplace free fromrecognizable hazards likely to cause death or serious harm”(OSHA, 1996). The United States Supreme Court ruled that pa-tients are entitled to safe conditions; this obligates hospitals toprovide a safe environment for patients and if patients are al-lowed to participate in aggressive behaviors without appropriaterepercussions, they will be more likely to have these negativeand antisocial behaviors reinforced (Quanbeck, 2006).

Since workplace safety is such a paramount issue, legislationat the federal and state level has been implemented in attemptsto curtail WPV. The State of California implemented two ini-tiatives to reduce WPV in hospitals and other types of healthcare facilities. In 1993, the California Occupational Safety andHealth Administration (Cal/OSHA) released their “Guidelinesfor Security and Safety of Health Care and Community ServiceWorkers” which provide a list of interventions and other WPVreduction approaches. Also in 1993, California passed the Cal-ifornia Hospital Safety and Security Act (Assembly Bill 508)which required all licensed acute care and psychiatric facilitiesto enact one of the previously suggested WPV prevention pro-grams. Hospital compliance was expected to occur by July of1995 (Cal/OSHA, 1993, 1998).

In 1994, the Federal Occupational Safety and Health Admin-istration (OSHA) recommended similar guidelines nationwide(OSHA, 1994). According to the General Duty Clause of theFederal OSHA Act, employers are required to “furnish each of

his employees a place of employment which are free from rec-ognized hazards that are causing or are likely to cause deathor serious physical harm to his employees” (OSHA, 1996).Twenty four states, Puerto Rico, and the Virgin Islands haveimplemented OSHA-approved State Plans.

RECOMMENDATIONS TO DECREASE WPVMultiple strategies have been proposed to increase reporting

of WPV. Paramount to the reduction of WPV is the participa-tion of management in the form of training, de-briefings, sup-port, staffing, and environmental modifications (Bowers et al.,2007; Morrison & Love, 2003). The education and training ofall staff, especially high risk staff (those that work in the ED orpsychiatric units) has been proposed by numerous researchers(Arnetz & Arnetz, 1999; Blanchard & Curtis, 1999; Catlette,2005; Deans, 2004; Findorff et al., 2005; Gallant-Roman, 2008a;Kamchuchat et al., 2008; Kowalenko et al. 2005; Lewis et al.,2007; Pawlin, 2008; Peek-Asa et al., 2007; Phillips, 2007; Whe-lan, 2008). Cal/OSHA (1993) recommended 28 various pro-grams/interventions for hospitals, which indicates that there arenumerous avenues for attempting to decrease WPV. There arealso many packaged WPV programs that hospitals can purchaseand tailor to fit their policies and procedures, protocols, and pa-tient populations. Most of these programs were designed for theeducational and institutionalized settings (schools, prisons, longterm behavioral facilities) and have elements that can easily beadapted to the health care setting. Even though these programsmay not have initially been designed for the health care setting,Egel and Torino (2006) state, “the lack of a systematic approachto identifying and controlling . . . risk factors leave staff andpatients vulnerable to violent behavior” (p. 13), agreeing thatsome type of systematic approach, such as these programs, isnecessary. Reporting of violent events and the improved abil-ity to recognize and de-escalate potentially violent situationssuccessfully may be a direct outcome of empowering nursesthrough this type of training and giving them the tools to beappropriately assertive in violent or potentially violent environ-ments (Arnetz & Arnetz, 1999; Deans, 2004; Findorff et al.,2005; Gallant-Roman, 2008b; Kowalenko et al., 2005; Phillips,2007). Training also should include the proper use of restraints,seclusion, and medications appropriate for the violent patient(Morrison & Love, 2003). Nurses must be provided tools toincrease feelings of self-efficacy to be able to identify and man-age violent behavior effectively (APNA, 2008; Whelan, 2008).Nurses felt better equipped to handle the violent situations afterattending WPV intervention programs (Ferns, 2005).

Numerous research studies exist in this particular body ofliterature that parse out which elements of these interventionprograms are consistently implemented. The most commonlycovered topics continue to be identifying the causes of ag-gression, communication techniques, and physical techniquesfor protection. The least commonly covered topics include re-view of hospital-specific policies and procedures, protocols,

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environmental modifications, pharmacologic management ofaggressive patients, and the appropriate use of restraints. Theleast likely topics to be included in these programs are resourcesthat are available to victims of WPV and reporting procedures(Calabro, Mackey, & Williams, 2002; Deans, 2004; Gates et al.,2005; Morrison & Love, 2003; Peek-Asa et al., 2007; Robinson& Tappen, 2008).

Initial training consists of a one or two day course witha yearly four hour refresher course thereafter. However, mostrefresher courses have been found to last only one hour or less(Peek-Asa et al., 2009). Also, physicians and other ancillarystaff, such as clerks, are often routinely excluded from thistraining (Morrison & Love, 2003; Peek-Asa et al., 2009).

Another type of training suggested by researchers is the uti-lization of the STAMP technique. STAMP stands for Staringand eye contact, Tone and volume of voice, Anxiety, Mum-bling, and Pacing and was developed by Luck et al. (2007b)as a way to predict violence. Nurses could use this tool as anassessment framework for identifying those with the potentialof violent behavior. This tool has potential for further researchand utilization for the prevention of WPV.

Support by administrators in terms of a zero tolerance policyhas also been suggested to decrease WPV (Armstrong, 2002;Gallant-Roman, 2008a; Whelan, 2008; Wiley, 2008). Supportcan be demonstrated in terms of violence prevention trainingprograms, yearly refreshers, and through providing the nec-essary tools and environmental modifications to provide safepatient care. Debriefings have been recommended to decreasepotential long term psychological consequences (Arnetz & Ar-netz, 1999; Catlette, 2005; Fernandes et al., 1999).

Support also comes in terms of staffing, as understaffingcan contribute to increased incidents of WPV and can triggercopycat violent events (Bowers et al., 2007; Jackson, Clare, &Mannix, 2002; Trinkoff et al., 2008).

Environmental modifications such as increased security, se-curity equipment (e.g., video cameras), appropriate monitoringof all entrances and exits, and adequate lighting have been shownto contribute to the prevention of WPV (Anderson, 2002; An-derson & Parish, 2003; Peek-Asa et al., 2009). The prominentpresence of security personnel has been shown to reduce the rateof assaults (Anderson & Parish, 2003; Trinkoff, Geiger-Brown,& Caruso, 2008;).

Quanbeck (2006) argues that when management ignores theproblem of WPV, staff morale is decreased, which ultimately isa contradiction to any therapeutic treatment. Nurses need to beaware of situations in which being assertive is essential to thesafety of staff and other patients. When nurses can recognizethe potential for violence accurately and intervene accordingly,they may feel better equipped to de-escalate and prevent simi-lar events in the future (Arnetz & Arnetz, 1999; Deans, 2004;Findorff et al., 2005; Gallant-Roman, 2008b; Kowalenko et al.,2005; Phillips, 2007).

Deans (2004) proposed a primary, secondary, and tertiary ap-proach to WPV. The primary approach included more preventa-

tive measures, which consists of identifying and owning healthcare worker’s responsibility in violent situations and postingwritten warnings to potential aggressors. Secondary preventionincludes reporting and documenting all types of abuse. Tertiaryprevention includes prosecuting perpetrators appropriately andproviding sufficient legal recourse.

IMPLICATIONS FOR FUTURE RESEARCHResearchers (Luck et al., 2007b) have developed tools for

predicting and reporting WPV and although promising, they arestill in their infancy and need to be validated in a larger morerepresentative sample of nurses. Also, the under-reporting ofWPV seems to be deeply rooted in societal constructs, gendersocialization, and the negative feedback of inaction. More edu-cational programs need to be implemented to expose nurses tothese multiple variables and provide the appropriate tools forassertive behavior, empowerment, and a call to the end of ac-cepted WPV (Blanchard & Curtis, 1999; Lau & Magarey, 2006;Whelan, 2008).

Future research should also focus on the reasons and contextof WPV, along with the interacting factors and the subsequentmanagement of violence utilizing this information (Lau & Mag-arey, 2006). Numerous studies also implicate the need for futureevaluation of educational programs and WPV prevention train-ing programs (Deans, 2004; Gates et al., 2006; Peek-Asa et al.,2002, 2007). Perceptions of health care workers, and specifi-cally nurses, as to what constitutes “acceptable” WPV and whatis unacceptable and therefore more likely to be reported shouldbe addressed as well.

A challenge for the future of research in this scholarly veinis to attempt to modify the culture and attitudes of the nursingprofession towards violence and aggression and ask why violentincidents are not reported. There is also no literature that bridgesthe gap between the nursing dynamic and the legislative andjudicial dynamics—meaning how to improve the efficacy ofreporting to those who can enforce or revise the laws that arecurrently in place.

CONCLUSIONTolerance for violence in the hospital and health care set-

ting by society and hospital administration must end (Gateset al., 2006; Whelan, 2008). This assertion is in concert withrecent Agency for Healthcare Research and Quality (AHRQ)patient safety and American Association of Critical Care Nurses(AACN) healthy workplace initiatives (AACN, 2004; Trinkoffet al., 2008). As highlighted in this review, more research needsto be conducted to synthesize a widely agreed upon and utilizeddefinition of WPV, which will help improve reporting rates ofWPV and spur a variety of interventions to decrease WPV. Theseinterventions would be developed by nurse as well as throughlegislative efforts to prevent or to set appropriate and enforce-able penalties for WPV. When hospitals are safer for staff, theywill be safer for patients.

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Declaration of interest: The authors report no conflicts ofinterest. The authors alone are responsible for the content andwriting of this paper.

REFERENCESAlexander, M. (2001). Violence in the emergency department: A firsthand ac-

count. Journal of Emergency Nursing, 27, 279–285.American Association of Critical Care Nurses. (2004). Workplace violence

position statement. Aliso Viejo, CA: Author.American Psychiatric Nurses Association. (2008). Workplace violence.

APNA 2008 position statement. Available: http://www.apna.org/files/public/APNA Workplace Violence Position Paper.pdf

Anderson, C. (2002). Past victim, future victim. Nursing Management, 33(3),26–32.

Anderson, C., & Parish, M. (2003). Report of workplace violence by Hispanicnurses. Journal of Transcultural Nursing, 14(3), 237–243.

Armstrong, F. (2002). Violence: It’s not part of the job. Australian NursingJournal, 9(9), 24–2.

Arnetz, J. E., & Arnetz, B. B. (1999). Implementation and evaluation of practicalintervention programme for dealing with violence toward health care workers.Journal of Advanced Nursing, 31(3), 668–680.

Blanchard, J. C., & Curtis, K. M. (1999). Violence in the emergency department.Emergency Medicine Clinics of North America, 17(3), 717–731.

Bowers, L., Allan, T., Simpson, A., Nimjan, H., & Warren, J. (2007). Adverseincidents, patient flow and nursing workforce variables in a psychiatric wards:The Tompkins Acute Ward Study. International Journal of Social Psychiatry,53(1), 75–84.

Calabro, K., Mackey, T. A., & Williams, S. (2002). Evaluation of trainingdesigned to prevent and manage patient violence. Issues in Mental HealthNursing, 23, 3–15.

Cal/OSHA. (1993). Guidelines for workplace security. Retrieved May 27, 2009,from http://www.dir.ca.gov/DOSH/dosh publications/worksecurity.html

Cal/OSHA. (1998). Guidelines for security and safety of health care and com-munity service workers. Retrieved May 27, 2009, from http://www.dir.ca.gov/DOSH/dosh publications/hcworker.html

Catlette, M. (2005). A descriptive study of the perceptions of workplace violenceand safety strategies of nurses working in Level I trauma centers. Journal ofEmergency Nursing, 31(6), 519–525.

Crilly, J., Chaboyer, W., & Creedy, D. (2004). Violence towards emergencydepartment nurses by patients. Accident and Emergency Nursing, 12, 67–73.

Deans, C. (2004). The effectiveness of a training program for emergency depart-ment nurses in managing violent situations. Australian Journal of AdvancedNursing, 21(4), 17–22.

Doherty, L. (2007). Victims of violence told to call police immediately afterincident. Nursing Standard, 21(49), 11.

Duncan, S. M., Hyndman, K., Estabrooks, C. A., Hesketh, K., Humphrey, C.K., Wong, J. S., Acorn, S., & Giovannetti, P. (2001). Nurses’ experienceof violence in Alberta and British Columbia hospitals. Canadian Journal ofNursing Research, 32(4), 57–78.

Egel, D., & Torino, T. M. (2006). Violence intervention prevention. Journal ofAddictions Nursing, 17, 13–19.

Fernandes, C. M. B., Bouthillette, F., Raboud, J. M., Bullock, L., Moore, C.F., Christenson, J. M., Grafstein, E., Rae, S., Ouellet, L., Gillrie, C., & Way,R. (1999). Violence in the emergency department: A survey of health careworkers. Canadian Medical Association Journal, 161(10), 1245–1248.

Ferns, T. (2005). Violence in the accident and emergency department—Aninternational perspective. Accident and Emergency Nursing, 1, 180–185.

Ferns, T. (2006). Under-reporting of violent incidents against nursing staff.Nursing Standard, 20(40), 41–45.

Findorff, M. J., McGovern, P. M., Wall, M. M., & Gerberich, S. G. (2005).Reporting violence to a health care employer. AAOHN Journal, 53(9),399–406.

Gallant-Roman, M. A. (2008a). Ensuring nurses’ safety in violent workplaces.AAOHN Journal, 56(2), 51–52.

Gallant-Roman, M. A. (2008b). Strategies and tools to reduce workplace vio-lence. AAOHN Journal, 56(11), 449–454.

Gates, D. M., Ross, C. S., & McQueen, L. (2005). Violence: Recognition, man-agement and prevention. Journal of Emergency Medicine, 31(3), 331–337.

Hampton, R. (2007). Protecting yourself from abusive patients. Practice Nurs-ing, 18(11), 539–542.

Hughes, J. (2006). Violence and health: The challenges of how we talk about,conceptualize, and address violence. Canadian Journal of Nursing Research,38(4), 27–30.

Jackson, D., Clare, J., & Mannix, J. (2002). Who would want to be a nurse?Violence in the workplace—A factor in recruitment and retention. Journal ofNursing Management, 10, 13–20.

Jansen, G. J., Dassen, T. W., & Jebbink, G. G. (2005). Staff attitudes towardsaggression in health care: A review of literature. Journal of Psychiatric andMental Health Nursing, 12, 3–13.

Kamchuchat, C., Chongsuvivatwong, V., Oncheunjit, S., Yip, T. W., & Santhong,R. (2008). Workplace violence directed at nursing staff at a general hospitalin Southern Thailand. Journal of Occupational Health, 50, 201–207.

Kowalenko, T., Walters, B. L., Khare, R. K., & Compton, S. (2005). Workplaceviolence: A survey of emergency physicians in the state of Michigan. Annalsof Emergency Medicine, 46(2), 142–147.

Lau, J. B. C., & Magarey, J. (2006). Review of research methods used toinvestigate violence in the emergency department. Accident and EmergencyNursing, 14, 111–116.

Lenehan, G.P. (2005). The aftermath of workplace violence: One person’s ac-count. Journal of Emergency Nursing, 31(6), 564–568.

Lewis, S., Dickinson, J., & Contino, D. S. (2007). Survey: Most ED staff victim-ized by violence never report incident. ED Management, 19(10), 109–120.

Little, L. (1999). Risk factors for assaults on nursing staff: Childhood abuse andeducation level. Journal of Nursing Administration, 29(12), 22–29.

Luck, L., Jackson, D., & Usher, K. (2007a). Innocent or culpable? Meanings thatemergency department nurses ascribe to individual acts of violence. Journalof Clinical Nursing, 17, 1071–1078.

Luck, L., Jackson, D., & Usher, K. (2007b). STAMP: Components of ob-servable behavior that indicate potential for patient violence in emergencydepartments. Journal of Advanced Nursing, 59(1), 11–19.

Mahoney, B. (1991). The extent, nature, and response to victimization of emer-gency nurses in Pennsylvania. Journal of Emergency Nursing, 17, 282–295.

Mattaini, M. A., Twyman, J. S., Chin, W., & Lee, K. N. (1996). Youth violence.In M. A. Mattaini & B. A. Thyer (Eds.), Finding solutions to social problems(p. 75–111). Washington, DC: American Psychological Association.

May, D. D., & Grubbs, L. (2002). The extent, nature and precipitating factors ofnurses assault among three groups of registered nurses in a regional medicalcenter. Journal of Emergency Nursing, 28(1), 11–17.

Mayhew, C., & Chappell, D. (2002). An overview of occupational violence.Australian Nursing Journal, 9(7), 34–35.

Morrison, E. F., & Love, C. C. (2003). An evaluation of four programs for themanagement of aggression in psychiatric settings. Archives of PsychiatricNursing, 17(4), 146–155.

Nachreiner, N. M., Hansen, H. E., Okano, A., Gerberich, S. G., Ryan, A. D.,McGovern, P. M., Church, T. R., & Watt, G. D. (2007). Difference in workrelated violence by nurse license type. Journal of Professional Nursing, 23(5),290–300.

Occupational Safety and Health Administration (OSHA). (1996). Public Law,91-596, December 19, 1970, and as admended by P.L. 101-552, Section 3101,November 5, 1990. Available online: http://www.osha.gov/Publications/OSHA3148/osha3148.htm#text2.

Oregon Nurses Association. (2009). 74th Oregon Legislative AssemblyWPVHB 2022 Retrieved June 2, 2009, from http://www.oregonrn.org/associations/3019/files/WPV%20LAW%20(%20HB%202022).pdf

Pawlin, S. (2008). Reporting violence. Emergency Nurse, 16(4), 16–21.

Issu

es M

ent H

ealth

Nur

s D

ownl

oade

d fr

om in

form

ahea

lthca

re.c

om b

y E

mor

y U

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rsity

on

08/2

4/13

For

pers

onal

use

onl

y.

WORKPLACE VIOLENCE AGAINST NURSES 95

Peek-Asa, C., Cubbin, L., Hubbell, K. (2002). Violent events and security pro-grams in California emergency departments before and after the 1993 HospitalSecurity Act. Journal of Emergency Nursing, 28(5), 420–426.

Peek-Asa, C., Casteel, C., Veerasathpurush, A., Nocera, M., Goldmacher, S.,OHagan, E., Blando, J., Valiante, D., Gillen, M., & Harrison, R. (2007)Workplace violence prevention programs in hospital emergency departments.Journal of Occupational and Environmental Medicine, 49, 756–763.

Peek-Asa, C., Casteel, C., Veerasathpurush, A., Nocera, M., Goldmacher, S.,OHagan, E., Blando, J., Valiante, D., Gillen, M., & Harrison, R. (2009).Workplace violence prevention programs in psychiatric units and facilities.Archives of Psychiatric Nursing, 23(2), 166–176.

Phillips, S. (2007). Countering workplace aggression. Nursing AdministrationQuarterly, 31(3), 209–218.

Quanbeck, C. (2006). Forensic psychiatric aspects of inpatient violence. Psy-chiatric Clinics of North America, 29, 743–760.

Ray, M. M. (2007). The dark side of the job: Violence in the ED. Journal ofEmergency Nursing, 33(3), 257–261.

Robinson, K. M., & Tappen, R. M. (2008). Policy recommendations on theprevention of violence in long-term care facilities. Journal of GerontologicalNursing, 34(3), 10–14.

Tang, J. S., Chen, C. L., Zhang, Z. R., & Wang, L. (2007). Incidences andrelated factors of violence in emergency departments—A study of nurses inSouthern Taiwan. Journal of Formos Medical Association, 106(9), 748–758.

Trinkoff, A. M., Geiger-Brown, J. M., Caruso, C. C., Lipscomb, J. A., Johantgen,M., Nelson, A. L., Sattler, B. A., & Selby, V. L. (2008). Personal safety fornurses. In R. G. Hughes (Ed.), Patient safety and quality: An evidenced basedhandbook for nurses. AHRQ Publication, 08–0043 (pp. 1–36). Rockville,MD. Agency for Healthcare Research and Quality.

U.S. Department of Labor. (2002). National census of fatal occupa-tional injuries in 2002. Retrieved June 30, 2009, from www.bls.gov/new.release/archives/cfoi 09172003.pdf

Whelan, T. (2008). The escalating trend of violence toward nurses. Journal ofEmergency Nursing, 34(2), 130–133.

Whittington, R. (2002). Attitudes toward patient aggression amongst mentalhealth nurses in the “zero tolerance” era: Associations with burnout andlength of experience. Journal of Clinical Nursing, 11(6), 819–825.

Wiley, K. K. (2008). 2007 Nebraska nurse survey results, making a world ofdifference: Workplace violence and nursing. Nebraska Nurse, 14–19.

World Health Organization. (2002). World report on violence and health.Geneva: Author.

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