Workplace Violence in Nursing on the Rise

 Meet the Expert: Gordon Gillespie, PhD, DNP, RN

Dr. Gordon Gillespie has been a registered nurse for over 25 years, working in emergency departments, public health, and academic settings. 

His work has been cited by the Occupational Safety and Health Administration, the U.S. Government Accountability Office, the American Nurses Association, and practitioners and researchers across six continents. He has chaired the national workplace violence conference, guest edited two interprofessional journal issues on workplace violence, co-chaired the Registered Nurses’ Association of Ontario’s second edition of the Best Practice Guideline “Preventing and Managing Bullying and Violence in the Workplace,” and served as an international director of the Emergency Nurses Association.

Workplace Violence Types

Workplace violence against nurses is divided into four types for research and tracking purposes. Dr. Gillespie explains that these types are based on the relationship between the healthcare worker and the aggressor. “Type one is criminal intent. It doesn’t happen as often, but it is things like somebody robbing a pharmacy. They’re not customers, and they’re there to commit a crime,” he says. “Type two is the one that’s most often talked about, and that’s from the customer or client. This includes verbal abuse, assault, and threats against you. Type three is coworker-on-coworker, which has had more talk lately. That includes bullying and incivility against one. Lastly, type four is intimate partner violence, and that’s rarely talked about. That’s where a current or past intimate partner comes into the workplace to harm you.”

The definition of workplace violence is more comprehensive than many people might assume. “If it happens while on duty or at the workplace, it is considered workplace violence. Even if you’re getting off work or walking to your car, it doesn’t matter who the person is,” explains Dr. Gillespie. “If you’re traveling between locations or moving between buildings, that’s time on the clock and included.”

Most Common Workplace Violence Against Nurses

Due to underreporting and the lack of studies comparing workplace violence against nurses, it can be hard to decipher what type is the most prevalent. “Historically, the most common type of violence we see is from patients and visitors against the worker. We hear more about bullying between nurses, so it’s hard to say which is greater right now. Because there are not a lot of studies that look at them together, it’s hard to say,” says Dr. Gillespie. 

He posits that violence from visitors and patients might be more simply because of numbers. “Think about how many patients you have on a shift compared to how many co-workers you might have. You might have one or two toxic coworkers, but that’s one or two people versus a whole group of patients that say whatever they want to say, do whatever they want to do, and don’t recognize that their behavior is inappropriate,” he says.

Causes of Workplace Violence In Nursing

According to Dr. Gillespie, the primary causes of workplace violence against nurses include stress or crisis, response to physical or mental distress, and a combination of entitlement or lack of education on how to behave appropriately. 

Some departments have a higher chance of encountering patients with one or more of these issues. “In the emergency department and psychiatric units, we are dealing with people who aren’t their normal selves because of instability in medications, a brain disorder, a chemical imbalance, mental health disease, withdrawal, or dementia. All those things contribute to the way they act. We understand it’s still unacceptable, but it tends to happen often because of the environment,” he says. “Sometimes they’re responding to painful stimuli like you’re putting in an IV catheter, and they swipe at you.”

Stress and crisis also contribute significantly to a patient’s misbehavior: “In the emergency department, you just have crisis after crisis. If your three- or four-year-old got hit by a car, and they were in the emergency department, you wouldn’t take well to a ‘Please sit down. We will be with you in a while’ from the staff. You’re going to get angry. You’ll probably call them some words you didn’t mean to. How many people will kick down a door when they hear their son or daughter cry?” asks Dr. Gillespie. 

Sometimes, entitlement or lack of education and understanding about different medical departments can be the catalyst for workplace violence: “People will present to the emergency room for a toothache and ask for pain medication when what they really need is an antibiotic and to have a tooth pulled or cleaned. Or they have an injury from a couple of years ago, and It’s still bothering them, and they want an MRI. That’s not an emergency. If we don’t do a good job communicating why we can’t provide the care they want, they will not be receptive to it and resort to being aggressive.”

Consequences of Violence Against Nurses

Violence against nurses in healthcare settings has serious consequences: “Nurses are getting tired of arguing with people about their disease diagnoses, and they’re now thinking maybe it’s time to find a different job or change departments or hospitals,” says Dr.Gillespie. “Some are returning to school for different careers because they just can’t take it anymore. Now, we have this massive staffing shortage. Part of it, too, is older adult nurses, with more years of experience,  are not willing to risk themselves anymore. 

The staffing shortage further exacerbates workplace violence. “Now nurses are working more often on short-staffed shifts, and when you’re short-staffed, that’s a precursor to violent events because people’s needs and wants can’t be addressed. It creates a spiral,” he explains. “Rates of PTSD are increasing amongst nurses because they’re now exposed to these traumatic events.”

Not only are nurses leaving because of workplace violence, but there has been a decrease in enrollment in nursing programs. The American Hospital Association notes a 1.4 percent decrease in baccalaureate program enrollment in 2022, the first time in 20 years there has been a decrease. Dr. Gillespie reports that programs he has known to be full for years have open seats they are desperate to fill. “Applicants absolutely consider workforce issues such as violence. They recognize that may not be what they want in life and will seek an alternative career,” he says.

Ways to Decrease Workplace Violence Against Nurses

“There are many different ways to decrease violence against nurses. One of the primary ways to do this is through prevention. It starts with the education for nurses and how they interact with patients. You have to decide: do you need to win this argument, or do you want to go home alive?”  Dr. Gillespie asks. 

“We need to think about it like standard customer service skills and education for communication. Ask, ‘What do you need? What do you want?’ And if there is disagreement, then agree to disagree and offer to follow up later. This is probably a five- to ten-minute conversation, which can be exhausting, but think of the time and people it takes to restrain someone. If ten people are managing one person for half an hour, that’s 300 minutes of care loss. That could have been prevented with a short conversation.

In addition to nurse training and education, facilities and managers can help as well: “A lot of hospitals do a lot to change the environment to reduce risk. One that works well is screening tools that help evaluate if a person is likely to become volatile,” shares Dr. Gillespie. “However, we need more education with our patients and visitors to clarify what the healthcare system can do for them. Whether you’re in the emergency department mental health unit, med surg, or perioperative care unit, they need to know what they will be doing today.” 

Lastly, Dr. Gillespie firmly believes that including patients and visitors in workplace violence vigilance can have a significant impact: “A sign that says we do not tolerate violence or assault and we will prosecute is a threat. If we flip it and say, ‘In our commitment to create a culture of safety, if you see anyone causing harm against someone else, please tell us right away’—that tells people everyone around you is watching you. That decreases a different sense that you can get away with something because everyone will report you. There are ways to communicate positively that we’re here to create a culture of safety for patients, family, visitors, and our staff.”