Workplace Violence: APNA 2008 Position Statement

Executive Summary Inpatient Violence in Psychiatric Settings Outpatient Psychiatric Settings Interventions
Recommendations for Inpatient and Outpatient Settings Appendix Acknowledgments References
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Violence in the workplace is a pressing concern for nurses in all settings and for psychiatric nurses in particular. In a large survey in 2007, the American Psychiatric Nurses Association (APNA) found that safety is one of the top issues of concern for registered nurses (RNs) working in mental health settings. Nurses serve as front-line care providers who practice in a wide variety of settings caring for individuals facing all types of trauma, suffering, and life-altering events.

In May 2007, the APNA Board of Directors commissioned a Task Force on Workplace Violence to examine the scope of the problem and to make recommendations for improving workplace safety. The task force steering committee was composed of a multinational group, representing a variety of practice settings. Focus areas for the task force included violence on inpatient settings (including private, forensic, and state funded), outpatient psychiatric settings, and other settings, specifically emergency departments (EDs) and home care. The emerging concern regarding horizontal violence, and the high-profile campus shootings compelled the task force to include aggression from coworkers and violence in schools and universities in the review. A volunteer panel of content experts conducted a comprehensive review of the literature in each of these areas of nursing by searching nursing, medical, and occupational health journals from 1970 to 2008. The APNA task force performed a review of the literature using the key words of psychiatric, nursing, and violence in the databases Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycINFO, and Academic Search Premier. While some international literature was reviewed, most was from North America.

The task force made recommendations specific to each area and assisted in the development of the final report. The findings of the task force are included in three position papers on workplace violence: (a) inpatient and outpatient psychiatric settings, (b) other health care settings, and (c) schools. This document, the first position paper, reports on workplace violence in both inpatient and outpatient psychiatric settings.

Initially, workplace violence was broadly defined as any physical assault, threatening behavior, or verbal abuse occurring in the work setting (Antai-Otong, 2001) or outside the workplace but related to work (Occupational Safety and Health Administration [OSHA], 2002, p. 1). The review, however, revealed a wide range of definitions and measurement strategies that are discussed in the context of the paper.

Workplace Violence: Scope of the Problem

Violence is a pervasive problem in our world community. Violent scenes depicted on television, video games, and in music and cinema are commonplace. Rage reactions and emotional breakdowns have been glamorized by substance-impaired celebrities. The extremes of domestic violence, road rage, gun violence, and mass murder in schools and other public places fill the evening news. Guns are easily accessible and assault rifles are designed for efficient mass slaughter. Today’s youth are intrigued by and desensitized to extreme violence. The darkly humorous euphemism, “going postal” is a sad testament to the way senseless acts of violence are minimized and inculcated into the American landscape.

Smoyak and Blair (1992) wrote about violence and abuse. They noted that at that time society was bombarded by violence and called for nonreactionary psychiatric treatment of patients moving toward progressive, understanding, and therapeutic care to reduce violence in clinical areas (Smoyak, S.A.. & Blair, D. T. 1992).

The International Council of Nurses (ICN) in 2006 reported that occupational violence is a major worldwide public health problem (Farrell, Bobrowski, & Bobrowski, 2006). According to a 2002 U.S. Department of Labor report, an estimated nearly 2 million acts of nonfatal work-related violence occur annually (Findorff, McGovern, Wall, & Gerberich, 2005). Work-related violence is the third leading cause of occupational injury fatality in the United States and the second leading cause of death for women at work (Findorff, McGovern, Wall, & Gerberich, 2005).

A 10-year study of rape occurring in the workplace in Washington State found that 11% of the rape victims were health care workers in hospitals or other nursing care facilities (Alexander, 5 Franklin, & Wolf, 1994). Hatch-Maillette and colleagues (2007) found that 63% of their sample—84% of whom were female nurses—reported a past incident of sexual threat, and 84% reported a past incident of physical or sexual assault.

Violence is one of the most vexing and risky hazards facing nurses in the psychiatric health care environment. There are clinical, ethical, legal, and political dimensions to this occupational hazard that can serve as formidable barriers to prevention and harm reduction. Inurnment due to chronic and protracted exposure to violent individuals, underreporting, few effective external regulations, and the belief that violence is “just part of the job” are just a few of the roadblocks to effective violence prevention (Love & Elliott, 2002).

In recent years, the health and safety consequences of horizontal violence (i.e., verbal, physical, and sexual abuse from coworkers) have received wide attention. A work environment with hostile interactions negatively impacts staff health and well being; furthermore, it has been associated with reduced quality of care and recruitment and retention problems. In 1982 Poster and Ryan studied assaults in psychiatric nursing, and in 1992 Lanza described nurses as victims of assault. It has only been since the early 1990s that violence has been considered a public and occupational health hazard (Lipscomb & Love, 1992).

The literature from 1970 to 1990 yielded articles which primarily described the characteristics of units where violence occurred and described the staff response to assault. Most of the inpatient violence research describes trends and patterns across populations and the effectiveness of various risk assessment technologies. There is a pressing need for research describing successful violence prevention interventions.

In recent years, the National Institute for Occupational Safety and Health (NIOSH) and the U.S. Department of Labor’s Occupational Safety and Health Administration (OSHA) have accelerated their efforts to study workplace violence and provide resources for employers. At the state level, only California, Washington, Florida, Illinois, New Jersey, Tennessee, and Nevada have passed laws requiring special violence prevention protections in health care workplaces. More recently, many organizations have adopted “zero tolerance” policies related to workplace violence. The 6 effectiveness of the various zero tolerance programs remain unclear, although they continue to grow in popularity. Beginning January 1, 2009, the Joint Commission on the Accreditation of Healthcare Organizations (Joint Commission) will require accredited health care organizations to have a formal process for managing behavior seen as unacceptable, such as a code of conduct and policies that support zero tolerance for violence and bullying. APNA recommends research in outcomes and means to these outcomes.

Without the provision of support, education, and training programs that address prevention and intervention techniques, policies alone cannot effectively reduce the incidence of workplace violence. Rew and Ferns (2005) note that government initiatives have been beneficial in highlighting managers’ responsibility to ensure the well being of their staff. They emphasize the importance of reporting and monitoring systems, but maintain that more emphasis is needed in recognition of the trigger factors to patient/client behavior, and its appropriate management.

In the past few years, nursing organizations, including the International Council of Nurses (ICN), the American Academy of Nursing (AAN), the American Nurses Association (ANA), and labor groups representing health care workers have advocated for improved protective regulations and research support to study effective risk management programs (McPhaul & Lipscomb, 2004). The Center for American Nurses has issued a statement on workplace violence as well as a position statement (February 2008) addressing bullying and other forms of horizontal violence in the workplace.

On July 9, 2008, the Joint Commission issued an alert regarding rude and disruptive behavior in health care settings. The Joint Commission states that

intimidating and disruptive behaviors can foster medical errors, contribute to poor patient satisfaction and to preventable adverse outcomes, increase the cost of care, and cause qualified clinicians, administrators, and managers to seek new positions in more professional environments. Safety and quality of patient care is dependent on more professional environments. Safety and quality of patient care is requires teamwork, communication, and a collaborative work environment. To ensure quality and to promote a culture of safety, health care organizations must address the problem of behavior that threaten the performance of the health care team. (Joint Commission, 2008)

Suggested actions include better systems to detect and deter unprofessional behavior, more civil responses to patients and families who witness bad acts, and overall training in basic business etiquette, including phone skills and people skills for all employees. Clearly, there is increased professional and organizational attention on workplace violence.

Incidence and Prevalence

According to the Bureau of Justice Statistics, workplace assaults injure 1.7 million workers each year (U.S. Department of Justice, 2001). In terms of injury rates from workplace violence, health care and social service industries are second only to the field of law enforcement (OSHA, 2003). Nearly 500,000 nurses become victims of violence in their workplace each year, according to the U.S. Department of Justice. Nurses are three times more likely to be the victims of violence than any other professional group (Keely, 2002). Three registered nurses in hospitals and five psychiatric nurses and home health aides died as a result of assaults and violent acts in the workplace in 2004 (U.S. Department of Labor, Bureau of Labor Statistics, 2005).

In Nursing Management’s 2008 Workplace Violence Survey, 1,377 of 1,400 respondents claimed that employee safety in health care is woefully inadequate (Hader, 2008). Nearly 74% of respondents experienced some form of violence in the work setting. This survey took place across the United States and in 17 other countries, including Afghanistan, Taiwan, and Saudi Arabia. Women made up 92.8% of the respondents, a gender distribution consistent with the nursing population as a whole. Most respondents worked in a hospital setting, followed by outpatient facilities, community health, academia, and rehabilitation. Of the types of violence encountered, 51% to 75% were bullying, intimidation, and harassment. Nearly 26% of respondents reported physical violence. Weapons were involved in 5.6% to 7.5% of the incidents. Perpetrators of violence against respondents included patients (53.2%), colleagues (51.9%), physicians (49%), visitors (47%), and other health care workers (37.7%).

Manderino and Berkey (1997) estimated that 90% of nurses experience verbal abuse on an annual basis. The Joint Commission surveyed nurses and found that more than 50% reported being subjected to verbal abuse (as cited in American Association of Critical Care Nurses, 2005, p. 16). Of the 303 nurses surveyed, 53% reported having been bullied at work (Vessey, Demarco, Gaffney, & Budin, in press).

It has been estimated that as few as one in five violent events are reported in psychiatric settings (Mayhew, 2000). Typically, violent acts that result in injury to patients or staff are reported, whereas acts of physical violence that do not result in injury or nonphysical types of violence are not reported. Findorff, McGovern, and Sinclair (2005) found that 43% of physical violence and 61% of nonphysical violence went unreported. Several factors may explain the low incidence of reporting in this study. Thirty-two percent of assaulted employees and 8% of those experiencing nonphysical violence reported that they considered violence to be part of the job, whereas others felt they were “telling on” a coworker or worried how reporting the incident would affect their working relationships.

In another study, Findorff, McGovern, Wall, et al. (2005) examined the individual and employment characteristics associated with reporting workplace violence and the relationship between the incidence of reporting and the characteristics of the violent event. Of those who experienced physical violence at work, 57% reported the events to their employer, compared to 40% who reported nonphysical violence. Frequency of assault and severity of symptoms were associated with the tendency to report. Women experienced more adverse symptoms and reported violence more frequently than men. Eighty-six percent of the reports of violence in this study were reported verbally rather than in writing.

There have been a number of reasons cited for the underreporting phenomenon:

  • peer pressure not to report (Lanza, 1988)
  • ambiguity in defining violence (Lanza, 1988)
  • excusing the behavior of “ill” patients (Mayhew, 2000)
  • perception that violence is part of the job (Lanza & Carifio, 1991; Mahoney, 1991; Poster & Ryan, 1994)
  • organizational culture (Farrell & Cubit, 2005; Mayhew, 2000), including onus on the victim to be proactive and make the complaint (Jackson & Mannix, 2002) and the employer’s belief that it would be too costly to institute protective measures for the staff 9
  • stigma of victimization, including embarrassment (Mayhew, 2000) and shame, isolation, and fear of judgment
  • fear of job loss (Poster, 1996)
  • fear of blame of provoking the assault or being negligent (Lanza, 1992; Lanza & Carifio, 1991)
  • victim’s self-blame (McCoy & Smith, 2001) • time-consuming, ineffective, or gender-biased reporting mechanisms (Mahoney, 1991)
  • no benefit, either personal or organizational, of reporting (Lanza, 1985; Mahoney, 1991; Poster & Ryan, 1989; Rose, 1997)
  • unhelpful experience with prior reporting

Types of Violence and Definitions

The Occupational Safety and Health Administration (OSHA) under the U.S. Department of Labor defines workplace violence as “any physical assault, threatening behavior, or verbal abuse occurring in the work setting.” A workplace may be any location either permanent or temporary where an employee performs any work-related duty (OSHA, 2004). “Workplace violence ranges from offensive or threatening language to homicide. National Institute for Occupational Safety and Health (NIOSH) defines workplace violence as violent acts (including physical assaults and threats of assaults) directed toward persons at work or on duty” (NIOSH, 2006). And the World Health Organization (WHO) defines workplace violence as "incidents where staff are abused, threatened or assaulted in circumstances related to their work, including commuting to and from work, involving an explicit or implicit challenge to their safety, wellbeing or health" (WHO, n.d.).

Workplace violence can be divided into four main types: physical, sexual, verbal, (Copeland, 2007, p. 2) and horizontal violence. Subtypes and definitions include:


  • assault—“attacks ranging from slapping and beating to rape, homicide, and the use of weapons such as firearms, bombs, or knives” (NIOSH, 2006). Other definitions are:
    (a) “a violent physical … attack,” or “a threat or attempt to inflict offensive physical 10 contact or bodily harm on a person (as by lifting a fist in a threatening manner) that puts the person in immediate danger of or in apprehension of such harm or contact” (Merriam-Webster, 2006);
    (b) “unwanted physical contact by a patient whether or not there is intent to harm. The contact may or may not result in injury. Physical assaults involve the use of force and include punching, kicking, slapping, biting, spitting, and thrown objects that hit another person” (National Database of Nursing Quality Indicators [NDNQI], 2005, p.1)
  • battery—“the act of battering or beating,” or “an offensive touching or use of force on a person without the person's consent” (Merriam-Webster, 2006); “assaults intended for the purpose of inflicting severe or aggravated bodily injury, usually accompanied by a weapon or by means likely to produce death or great bodily harm” (U.S. Department of Justice, as cited in Brumbaugh-Smith, Gross, Wollman, & Yoder, 2008, p. 366)
  • physical harassment—“to create an unpleasant or hostile situation … especially by uninvited and unwelcome … physical conduct” (Merriam-Webster, 2006)
  • homicide—“killing of one person by another” (Copeland, 2007, p. 23)
  • mugging—“aggravated assaults, usually conducted by surprise and with intent to rob” (NIOSH, 2006)


  • rape—sexual intercourse with a person “forcibly and against her will including attempt or assaults to rape” (U.S. Department of Justice, as cited in BrumbaughSmith et al., 2008, p. 366)
  • fondling— consisting of words, conduct, or action of a sexual nature, directed at a specific person, that annoys, alarms, or causes substantial emotional distress to that person” (Garner, as cited in Copeland, 2007, p. 23)


  • threat—Expressions of intent to cause harm, including verbal threats, threatening body language, and written threats (NIOSH, 2006); explicit or implied expression to inflict pain, injury, or harm to another (Privitera, Weisman, Cerulli, Tu, & Groman, 2005)
  • verbal abuse— Yelling, swearing, intimidating, demeaning, public scolding, and/or sexually harassing, using words (Carroll, 2003)

Horizontal violence, which can be verbal or nonverbal:

  • hostility—“deep-seated … ill will” or “conflict, opposition, or resistance in thought or principle” (Merriam-Webster, 2006)
  • verbal harassment—“to annoy persistently” or “to create an unpleasant or hostile situation … especially by uninvited and unwelcome verbal … conduct” (MerriamWebster, 2006)
  • bullying—when a person “intentionally exerts power or intimidation in a manner that leads [the victim] to feel that there may be a threat to his or her personal well-being” (ICN, as cited in Kolanko et al., 2006, p. 38) in a pattern occurring over time (Einarson, 1999); “repetitive aggressive behavior from a person of higher position or power with the deliberate intent to cause psychological or physical harm” (Vessey, DeMarco, Gaffney, & Budin, in press); frequent objectionable behavior imposed upon an employee by another person (MacIntosh, 2006)

Nonverbal aggression (i.e., disparaging looks and noises, offensive gestures, ignoring another, and physically standing over another with the intention of intimidating) are all forms of bullying and workplace abuse (Murray, 2007, 2008). Vessey, Demarco, Gaffney, and Budin (in press) define bullying as “repetitive aggressive behavior from a person of higher position or power with the intention to cause psychological or physical harm” (Center for American Nurses, LEAD Summit, 2008).

Five categories of workplace bullying described by Rayner and Hoel (1997) are: (a) threat to personal status, such as belittling opinion, public professional humiliation, and accusation of lack of effort; (b) threat to personal standing, such as gossiping, name calling, insults, and teasing; (c) isolation, such as preventing access to work opportunities, physical or social isolation, and withholding of information; (d) overwork, such as undue pressure to produce work, impossible deadlines, and unnecessary disruptions; and (e) destabilization, such as failure to give credit when due, meaningless tasks, removal of responsibility, shifting of goals, repeated reminders of error, and setting up to fail (Rayner & Hoel, 1997, p. 183).

Workplace violence can also include manipulation of the working environment, that is, withholding needed information, setting unreasonable deadlines, excluding from critical meetings, changing work schedules unfairly, failing to give credit, and retarding opportunities for advancement, promotion or higher pay. To meet the definition of workplace violence or abuse these offenses must occur repeatedly and over time (Murray, 2007, 2008).

Risk Factors for Horizontal Violence

The literature reveals numerous factors that contribute to horizontal violence in the workplace:

  • greater amount of time spent at work (Harvey & Keashly, 2003) or high workload (Quine, 1999)
  • female senior manager in a male-dominated organization, with low job control and lack of participation in decision-making processes (Quine, 1999)
  • shift rounds as a high occurrence time for bullying (in a neonatal intensive care unit) (Patole, 2002)
  • lack of nursing staff cohesion and positive leadership, associated with aggression (Rew & Ferns, 2005)
  • victim’s low self-esteem (Harvey & Keashly, 2003; Randle, 2003;) and lack of assertiveness (McCabe & Timmins, 2006)

Consequences of Horizontal Violence

Exposure to bullying, and verbal and physical abuse from superiors and coworkers drains nurses of their enthusiasm for the profession and undermines job satisfaction and employee morale (Thomas, 2003). Insider-initiated aggression also appears to lower employees’ commitment to their organization, although aggression by a member of the public does not (LeBlanc & Kelloway, 2002).

Costs to organizations include low worker morale, absenteeism, sick leave, property damage, early retirement, high turnover, grievances and litigation, increased accidents, decreased performance and productivity, security costs, worker's compensation, reduced trust of management, and loss of public prestige (Gilioli, Campanini, Fichera, Punzi, Cassitto, 2006; Jackson & Mannix, 2002; McKenna, Smith, Poole, & Cloverdale, 2003; NIOSH, 2002; Speedy, 2006). The direct effect of horizontal violence on productivity has yet to be determined. Hoel, Rayner, and Cooper (1999) noted that persons subjected to bullying might be more eager to demonstrate their ability and commitment because of feelings of low self-esteem.

Horizontal violence affects recruitment. In a study by Curtiss, Bowen, and Reid (2007), about 90% (77) of the 86 nursing students reporting or witnessing horizontal violence responded that their experiences would affect their employment choices.

Study findings are mixed about the emotional and psychological impact of horizontal violence on nurses. Several studies found that horizontal violence contributes to lower levels of job satisfaction, higher levels of job-induced stress, and increased likelihood of clinical anxiety and depression (Longo & Sherman, 2007; Quine, 1999; Taylor & Barling, 2004). Farrell (1999) found horizontal violence to be more disturbing to nurses than other distressing work issues, such as workload or emotional needs of patients, whereas Hillhouse and Adler (1997) reported that nurses did not identify conflict with other nurses as stressful.

Bullying has harmful effects on health. Quine (1999) examined workplace bullying among 396 nurses with a questionnaire that included questions about emotional and somatic illness. Nurses who experienced being bullied perceived that it affected their health both physically and mentally. They reported an increase in drinking and smoking behaviors and a decreased ability to sleep. Targets of bullying behaviors did report various response strategies including ignoring the behavior, talking to friends, issuing a formal complaint, and directly confronting the perpetrator.

Workplace violence can also include manipulation of the working environment, that is, withholding needed information, setting unreasonable deadlines, excluding from critical meetings, changing work schedules unfairly, failing to give credit, and retarding opportunities for advancement, promotion or higher pay. According to Murray (2007, 2008), to meet the definition of workplace violence or abuse these offenses must occur repeatedly and over time.

Effective policies regarding workplace violence, grievance procedures, and counseling are methods to reduce workplace violence (Howard, 2001). Every health care organization should have a comprehensive plan for workplace violence, including horizontal violence. The administration and managers should:

  1. Establish a steering committee to define workplace violence and establish a plan of action.
  2. Survey staff attitudes about intimidation and lateral violence.
  3. Create a code of conduct and have existing and new staff sign the code, at their hire and annually.
  4. Hold frank discussions about workplace violence using objective moderators.
  5. Establish a standard, assertive communication process (Griffin, 2004).
  6. Create a conflict resolution process stated in a professionalism policy and include a chain of command for resolution.
  7. Encourage one-on-one conflict resolution and provide a mechanism for confidential reporting.
  8. Enforce a zero tolerance policy (full punishment for an infraction) (Hader, 2008; Joint Commission, 2008).
  9.  Provide ongoing education to reinforce the organization’s commitment to ensuring a caring and respectful environment.
  10. Lead by example and reward outstanding role models (Schaffner, Stanley, & Hough, 2006).

A concern with the use of the term zero tolerance is the possibility that violent acts will be reported less often if the policy states “zero tolerance,” which implies certain consequences from the employer. With the Joint Commission now using the term of “zero tolerance” in the sentinel alert effective January 2009 regarding disruptive behavior, it is apparent the term is increasing in use and zero tolerance for violence and bullying is becoming the normative practice in the workplace.

In an attempt to reduce horizontal violence, Griffin (2004), in a controlled study without randomization, taught “cognitive rehearsal” to newly graduated nurses. These nurses received education on horizontal violence, role modeling, and rehearsal in an interactive session and then received cue cards with a script and professional behaviors to act out for each of 10 identified types of horizontal violence (see Appendix). At the end of the training, participants reported using their skills when experiencing horizontal violence and reported that the training prevented further acts of horizontal violence. The retention of newly registered nurses during this first year was 91%, when the national average has been described between 40% and 60% (Griffin, 2004).


An act that can cross all types of violence is stalking. Stalking is “a crime involving threatening and potentially dangerous acts of pursuit of an individual over time” having three elements: “a pattern of unwanted behavioral intrusion,” an implicit or explicit threat,” and “fear as a result of these behavioral intrusions” (Maxey, 2003, p. 30).

Typology of Workplace Violence

NIOSH subscribes to a typology of workplace violence that the Injury Prevention Research Center (IPRC) at the University of Iowa (2001) developed. Table 1 lists this typology (NIOSH, 2006, p. 6). NIOSH states that definitions of workplace violence are as yet not consistent among government agencies, employers, workers, and other interested parties. One of its agenda items for partnerships with research institutions is to develop consistent definitions of workplace violence (NIOSH, 2006).

Table 1. Typology of workplace violence
Type Description
I: Criminal intent The perpetrator has no legitimate relationship to the business or its employee, and is usually committing a crime in conjunction with the violence. These crimes can include robbery, shoplifting, trespassing, and terrorism. The vast majority of workplace homicides (85%) fall into this category.
II: Customer/client The perpetrator has a legitimate relationship with the business and becomes violent while being served by the business. This category includes customers, clients, patients, students, inmates, and any other group for which the business provides services. It is believed that a large portion of customer/client incidents occur in the health care industry, in settings such as nursing homes or psychiatric facilities; the victims are often patient caregivers. Police officers, prison staff, flight attendants, and teachers are some other examples of workers who may be exposed to this kind of workplace violence, which accounts for approximately 3% of all workplace homicides.
III: Worker-onworker The perpetrator is an employee or past employee of the business who attacks or threatens another employee(s) or past employee(s) in the workplace. Worker-on-worker fatalities account for approximately 7% of all workplace homicides.
IV: Personal relationship The perpetrator usually does not have a relationship with the business but has a personal relationship with the intended victim. This category includes victims of domestic violence assaulted or threatened while at work, and accounts for about 5% of all workplace homicides.
Note: From NIOSH, 2006.

Crimes of violence—Type I in the NIOSH typology—include rape, gender sexual assault, robbery, and assault (Bureau of Justice Statistics, 2008).

Type II violence in the health care setting often victimizes patient caregivers, including nurses.

Type III, worker-on-worker violence, may occur vertically—when workers in authority positions perpetrate violence over those in lower positions, when staff members in lesser positions are violent toward those in higher positions, or when a vertical workplace event is reflected. A study by Sofield and Salmond (2003) found primarily physicians, then patients, and lastly patients’ families were responsible for the most verbal abuse of nurses. The Institute for Safe Medication Practices published a survey in 2004 on reporting of intimidation and found that almost 50% of 2,095 respondents, including nurses, pharmacists, and other health care providers, recalled that a physician verbally abused them when they wanted to clarify orders (Center for American Nurses, 2008). Quine (1999), however, found the most common perpetrator of bullying to be senior managers.

Another form of type III violence is between workers holding the same or similar positions, termed horizontal violence or lateral violence. The most frequent manifestations of horizontal aggression are not acts of overt aggression but less dramatic psychologically aggressive acts, such as spreading rumors about and giving dirty looks to colleagues (Baron, Neuman, & Geddes, 1999). Also common are nonverbal innuendos, verbal affronts, undermining activities, withholding information, sabotage, infighting, scapegoating, backstabbing, failure to respect privacy, and broken confidences (Duffy, 1995; Farrell, 1997, 1999; McCall, 1996). Acts of horizontal violence also can include belittling or criticizing a colleague in front of others, blocking a chance for promotion, and isolating or freezing a colleague out of group activities (Longo & Sherman, 2007). Studies have shown that a high prevalence of nurses (Griffin, 2004; Stanley, Martin, Michel, Welton, & Nemeth, 2007; Vessey, DeMarco, Gafney, & Budin, in press) and nursing students (Longo, 2007) witness or experience horizontal violence in practice settings. However, one survey reported that, despite this high prevalence, 75% of nurse respondents perceive that their coworkers often treat them with courtesy and respect (Stanley et al., 2007).

Domestic violence occurring in the workplace is considered type IV aggression. According to the U.S. Department of Labor (1996), homicide is the leading cause of death for women on the job, and for 17% of these women, their killer is an intimate partner. Although personality conflicts between employees, employers, and customers account for most workplace violence incidents, family and marital problems define 15% of incidents (Stouffer & Varnes, 1998). The National Safe Workplace Institute’s national survey conducted in the mid-1990s found that 94% of corporations’ security directors ranked domestic violence as a high security problem for their companies (Marmer-Solomon, 1995). Worksite harassment correlates positively with actual physical domestic violence (McFarlane et al., 2000).

Some university centers have been working to identify occupational violence and develop related definitions. For example, the Peace Studies Institute at Manchester College in Indiana has done extensive research on ways to measure violence in the United States. The institute developed the National Index of Violence and Harm (NIVAH), used to identify trends in interpersonal, intrapersonal, institutional, and structural violence (Brumbaugh-Smith et al., 2008).

In the National Index of Violence and Harm (NIVAH), Brumbaugh-Smith and colleagues further conceptualize violence into personal and societal, including two categories in each. Personal violence can be either (a) interpersonal, which is “harm between people,” or (b) intrapersonal, “harm done to oneself” (Brumbaugh-Smith et al., 2008, p. 354). They group societal violence into (a) institutional violence, “violence that occurs by the action of societal institutions … by individuals whose actions are governed by the roles that they are playing in an institutional context” (Brumbaugh-Smith et al., 2008, p. 354), and (b) structural violence defined as “harm done by the overall structuring of society” (Brumbaugh-Smith et al., 2008, p. 354). Institutional violence is further grouped into government, corporate, and family. Using this framework, it appears that workplace violence is mainly interpersonal and institutional.

Consequences of Violence

Nurses who have been assaulted experience both physical and emotional consequences including traumatic injuries and even death. The majority of physical injuries due to patient violence tend to be minor, although career-ending incidents involving permanent disability are not uncommon (Hunter & Carmel, 1992). Caldwell (1992) found that approximately half of the assaulted staff experienced minor injuries. Nijman and Palmstierna (2005) found that only 1% to 5% of the reported aggressive incidents resulted in injury requiring medical attention. 19 The impact of an assault is often underestimated because physical injury is the most common measure used to assess impact. However, individuals have strong emotional and psychological reactions to assaults and threats of assault regardless of whether or not injury was sustained.

The emotional consequences of workplace violence include anxiety, depression, insomnia, stress-related disorders, and loss of self-confidence (Gilioli et al., 2006). In one study approximately 78% of health care employees experienced at least one adverse symptom in response to work-related violence, while 20% of those physically assaulted and 25% of victims of nonphysical violence experienced five or more troublesome symptoms (Findorff, McGovern, & Sinclair, 2005).

Burnout and exhaustion are associated with verbal abuse (Grandey, Kern, & Frone, 2007; Thomas, 2003). Bullying is associated with fear, demoralization, hypertension, panic attacks, lower morale at work, and negative relationships at work (Hutchinson, Wilkes, Vickers, & Jackson, 2008). Sexualized violence sometimes can evoke strong psychological reactions from staff (Sandburg, McNiel, & Binder, 2002).

The frequency of post-traumatic stress disorder (PTSD) following workplace violence mirrors that of other traumatic life events. Caldwell (1992) found that of staff members who reported experiencing an assault, 61% of the clinical staff and 28% of the nonclinical staff reported symptoms of PTSD. Ten percent of clinical staff and 7% of nonclinical staff met the diagnostic criteria for PTSD.

It is noteworthy that Caldwell (1992) found that most of the assaulted employees in the study did not take advantage of employer-provided resources such as occupational health services or the Employee Assistance Program (EAP).

Anxiety and stress about personal safety exacerbates other inherent work stressors (Erickson & Williams-Smith, 2000). O’Connell, Young, Brooks, Hutchings, and Lofthouse (2000) found a direct link between workplace aggression and increases in nurses’ sick leave, drug and alcohol use, burnout, and staff turnover. Violence and an adverse psychosocial work environment are related to poor health and a low commitment to nursing (Lawoko, Joaquim, Soares, & Nolan, 2004). In different care situations, violent episodes of both a physical and a verbal nature were found to increase intent to leave nursing (Sofield & Salmond, 2003).

It is noteworthy that studies addressing the effects of violence on patient victims and patient witnesses are rare.

Financial Costs

The National Institute for Occupational Safety and Health (NIOSH, 2002) found that employees lost a total of 160 days due to patient violence. Lanza (1983) surveyed 40 nursing staff in a Veterans Affairs (VA) psychiatric hospital and found that 45% reported losing time from work due to patient assault. Lanza and Milner (1989) reported the annual cost from inpatient violence to be approximately $38,000. Two of eight staff members incurring medical expenses and 78 days from work cost more than $6,200. Hunter and Carmel (1992) found that patient assaults in 1 year cost $766,290.

At a presentation at the Center for American Nurses 2008 LEAD Summit, Colonel John S. Murray, President of the Federal Nurses Association, conservatively estimates the cost of violence in the workplace at $4.3 million annually or approximately $250,000 per incident, excluding hidden expenses from the emotional pain of victims, witnesses, and families suffering with anxiety, depression, and feelings of isolation (Murray, 2008).

The costs associated with workplace violence have major implications for the health of the workforce and the organization. Rew and Ferns (2005) include the following:

  • increased staff turnover, recruitment, and retention costs
  • increased staff absence from work
  • reduced efficiency and performance at work
  • reduced staff morale
  • reduced staff numbers, especially the loss of experienced staff, leading to increased pressure on remaining staff
  • higher incidence of patient complaints
  • higher risk of increased frustration by patients and staff
  • higher risk of violent incidents
  • falling reputation for the organization

Clearly, health care organizations and other employers have not only a social responsibility but also an enormous financial incentive to prevent workplace violence.


Executive Summary Inpatient Violence in Psychiatric Settings Outpatient Psychiatric Settings Interventions
Recommendations for Inpatient and Outpatient Settings Appendix Acknowledgments References
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