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November 19, 2014

Editor’s Note: It was only earlier this month that another attack on nurses was reported, this time at a hospital in

Minnesota, when it appears that a patient suddenly became violent and attack ed nurses with a metal bar tak en from

his hospital bed. The frightening video shows how the nurses were attack ed as they sat in the nurses’ station in the

middle of the night.

Brutal Attacks on Nurses

A nurse approached a patient’s bedside to remove an intravenous (IV) catheter in preparation for discharge from the

hospital.[1] He lunged at her, hitting her with an IV pole and knocking her to the ground, stomping on her head, and

beating her repeatedly until she became unconscious. The nurse suffered head trauma and multiple fractures to her

face. She survived the attack but required neurosurgery and was in critical condition for some time. The patient, who

was not known to be dangerous, apparently became angry when told he was being discharged from the hospital.

Fortunately, such extreme incidents of violence are not everyday occurrences in healthcare. Still, they do happen, as

illustrated by the following headline-making incidents:

• At a psychiatric hospital in Maine, a patient attacked a nurse with a chair, injuring her face and head. In an earlier

incident in the same unit, another angry patient beat a nurse in the head and stabbed her with a pen.[2]

• A corrections facility nurse in Michigan was checking on an inmate whom she thought was having a seizure, when

he jumped up and attacked her.[3]

• At an ambulatory surgery center in Texas, a patient’s son accused staff of trying to kill his mother, and he fatally

stabbed a nurse who tried to protect other patients from harm.[4]

• At a rehabilitation facility in Oklahoma, a man became angry when nurses removed his father’s urinary catheter,

attacking a nurse with a wrench, pulling out some of her hair, and forcing her into a medication room.[5]

• In California, two incidents took place on the same day in different nearby hospitals. A visitor bypassed a weapons

screening station and purportedly stabbed a nurse 22 times. In the second incident, a visitor grabbed a nurse and

stabbed her in the ear with a pencil.[6]

These events show that attacks on nurses can be sudden, serious, and life-threatening. They take place in a broad

range of settings and involve patients, family members, and visitors who become angry for seemingly minor reasons

or for no apparent reason at all. Violence against nurses is more frequent in, but not limited to, the emergency

department (ED) or psychiatric units. It can happen in any healthcare setting, at any time. The unpredictable nature

of workplace violence in healthcare is what makes it so difficult to prevent.

And the violence is not just physical. Emotional, sexual, and verbal abuse are not only more common, but are much

more likely to be unreported. Nurses who are threatened with physical violence, but unharmed, do not always report

the incident to their supervisors. Thus, firm figures on the frequency of workplace violence in healthcare are elusive.

Reading about these incidents of violence is a little scary. After all, no nurse goes to work expecting to be physically

assaulted. Fortunately, the problem of workplace violence has not gone unnoticed by healthcare researchers, and

new data are expanding our understanding of the threat to nurses.

Step Away From That Nurse! Violence in Healthcare Continues
Unabated
Laura A. Stokowski, RN, MS

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A disheartening trend evident in the healthcare literature is that violence against nurses appears to be a growing

problem globally.In the past 2 years alone, articles have been published in the professional literature on violence

against nurses in the United Kingdom,[7] Ireland,[8] Australia,[9] New Zealand,[10] Switzerland,[11] Sweden,[12]

Slovenia,[13] Greece,[14] Turkey,[15] Cyprus,[16] Pakistan,[17] Iran,[18] Jordan,[19] Egypt,[20] Nigeria,[21] sub-Saharan

Africa,[22] Japan,[23] and China.[24]

Harassment to Homicide

If you have been a victim of workplace violence, you know what it is and what it feels like. Workplace violence is any

physical assault, threatening behavior, or verbal abuse directed at those who are at work or on duty.[25] Violence

includes overt and covert behaviors ranging in aggressiveness from verbal harassment to homicide.

Workplace violence can have both physical and psychological effects on the victim.Although the workplace violence

“umbrella” also includes worker-to-worker (lateral or horizontal) violence, this article focuses on violence perpetrated

by patients, family members, visitors, or other strangers in the healthcare setting.

When Dan Hartley, EdD, workplace violence prevention coordinator at the National Institute for Occupational Safety

and Health (NIOSH), is speaking to nursing groups, he wants to find out how many nurses in the audience have

experienced workplace violence. “I’ve learned to say, ‘Raise your hand if you have never experienced workplace

violence,'” says Hartley. “It’s much easier to count the hands because so few of them go up.”

What Do the Numbers Say?

Although no one disputes the fact that violence occurs in healthcare, we are still hampered by a dearth of firm

statistics about the prevalence of workplace violence in healthcare settings. Data are collected from the Bureau of

Labor Statistics (BLS) only on episodes of nonfatal violence that result in days lost from work—in other words,

episodes that are reported and cause sufficient injury for the nurse to take time off from work.

However, surveys of nurses about their experiences with workplace violence suggest that, as a rule, only the most

serious incidents are reported. Many nurses neglect to report workplace violence if they haven’t been physically

harmed, if they “excuse” the perpetrator’s behavior for some reason, or if they believe that it is unlikely to be repeated

(because the patient or visitor is gone from the facility, for example, or the nurse is not scheduled to work the

following day).

Bearing in mind that they severely underestimate the prevalence of workplace violence involving nurses, the few

available statistics can do no more than hint at the scope of the problem, but they do suggest that violence is

increasing rather than decreasing.

BLS keeps statistics on the number of nonfatal workplace injuries that required days off from work. In 2012, a total of

19,360 episodes of violence or other injuries inflicted by persons or animals were reported in healthcare and social

assistance, almost equally divided between acts that were intentional and those that were considered unintentional or

intent unknown.[26] This equates to a rate of 15.1 incidents per 10,000 full-time workers,[27] and it represented a 6%

increase in violence against healthcare and social assistance workers.[28] When broken down by healthcare setting,

5910 incidents occurred in hospitals (15.6 per 10,000), 8990 in nursing or residential care facilities (37.1 per 10,000),

and 1790 (3.7 per 10,000) in ambulatory care centers and offices.[27] Considering reports by provider type, in 2012, a

total of 2160 episodes of workplace violence against registered nurses and 780 against licensed practical/vocational

nurses were reported.[29]

Most likely, these data underrepresent true rates of nonfatal workplace violence. We know from survey data of nurses

that workplace violence is common. A recent survey of 764 primarily white, female nurses employed by a large,

multihospital urban/community hospital system asked nurses how often they experienced episodes of physical or

verbal violence, and what they believed to be the causes of these incidents.[30] The survey response rate was 15.2%.

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During the past year, 76% experienced violence (verbal abuse by patients, 54.2%; physical abuse by patients,

29.9%; verbal abuse by visitors, 32.9%; and physical abuse by visitors, 3.5%), such as shouting or yelling, swearing

or cursing, grabbing, scratching, or kicking. Emergency nurses (12.1%) experienced a significantly greater number of

incidents (P < .001). The perpetrators were primarily white male patients, aged 26-35 years, who were confused or

influenced by alcohol or drugs.

Do Nurses Report Workplace Violence?

Nurses were also asked whether they reported these incidents of violence; reasons cited for not reporting included

not sustaining physical injury (49.5%), inconvenience (26.1%), and the perception that violence comes with the job

(19.6%). Other prominent reasons included being unclear about reporting policies, not wanting to draw attention to

oneself, and fear of retaliation or reprisals. Other evidence confirms that many nurses take a fatalistic view of reporting

workplace violence. They believe that reporting it is a waste of time, and nothing will be done about it anyway.[13]

Hartley finds another reason that some nurses don’t report workplace violence. “Some nurses don’t understand what

constitutes workplace violence. A patient might strike out at a nurse while he or she is giving a med, but that

happens all the time. Or nurses say that they only report violent behavior if they have to go the ED.” Hartley tells of a

nurse who worked in a nursing home who had an “aha moment” at a workplace violence seminar. “I never thought of

being hit, kicked, or spit on by patients as violence, until I realized one day that it was the same patients doing it over

and over again. We weren’t reporting it, so no one pinpointed the problem and nothing was ever done.”

Workplace violence can, and has, happened in any area of healthcare. Although it is most frequent in three areas—

the ED, mental health settings, and geriatric care—no healthcare setting is immune. Violence toward nurses has

happened in labor and delivery, pediatrics, and ambulatory care. It happens in patients’ rooms, waiting rooms, and

even in patients’ homes. Workplace violence affects all healthcare workers, but nurses are the most likely to be

assaulted on the job.[31]

Healthcare Settings: High-Risk Workplaces

Like the nurse who has gotten used to patients striking out at her, nurses are often heard to say that violent acts by

patients and visitors are “just part of the job.” Has violence become so prevalent in healthcare that it must now be

accepted as “going with the territory?”

“We tell nurses that violence isn’t part of your job,” says Hartley, “but violence prevention should be. The risk factors

for violence are more common in healthcare settings.”

NIOSH divides the risk factors for violence into three categories: clinical, environmental, and organizational.[32]

Clinical risk factors are those that relate to the patient, family member, visitor, or other individual, and include such

characteristics as being under the influence of drugs or alcohol, having a history of violence, or being in the criminal

justice system. Sometimes, a reaction to a healthcare provider who is perceived as being authoritarian or who used

excessive force in the course of care can prompt anger. Some medical and psychiatric diagnoses are risk factors for

violence, although most people with mental illness are not violent.

Environmental risk factors for violence are features of the layout, design, or amenities of the setting that might

provoke frustration or anger, such as confusing signage, a lack of parking, or prolonged waiting. The environment can

also elevate risk by providing such opportunities for undetected violence as unmonitored stairwells, insufficient

lighting, or furniture and other items that could thrown or used as weapons. A lack of security systems, alarms, or

“panic buttons” to call for help can restrict a staff member’s ability to respond appropriately to a sudden threat.

Organizational risk factors include inadequate attention to the risk for violence in the workplace, a lack of staff training

to prevent and manage violence, inadequate security and preparedness, and inadequate staffing.

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Can Healthcare Violence Be Predicted?

It would be unrealistic to suggest that violence can ever be completely eradicated from the healthcare environment

however many zero-tolerance policies are implemented. When people are sick or injured, emotions run high. People

are stressed, anxious, and unhappy. A more productive approach is to identify the behavioral cues that might foretell

violent behavior, and the situations most likely to precipitate violence, in line with the philosophy that “forewarned is

forearmed.”

Picking up on the behavioral cues for violence has obvious benefits for the individuals in the line of fire, and an

increased awareness about the catalysts for violence can help healthcare facilities bolster their security and response

mechanisms. Electronic health records and data entry have made this type of analysis possible, but the benefits will

be realized only if nurses and others are encouraged to make reports for every incident of workplace violence,

regardless of whether physical injury occurs or the perceived intent of the action.

A recent study[33] assessed the situational factors that seemed to most frequently precede violent behavior on the

part of patients toward nursing staff. Using data from a centralized reporting system, all incidents (n = 214) during a

single year (2011) at an urban hospital were analyzed. These incidents were reported by nurses (39.8%), security

staff (15.9%), and nurse assistants (14.4%). Incidents of violence were found to be linked to specific patient

characteristics and behaviors (cognitive impairment, pain or discomfort, demanding to leave), patient care (use of

needles, use of restraints, physical transfer of patients), or situational factors (transitions in care, intervening to

protect patients or staff, and redirecting patients).

Another study[34] supports the fact that psychiatric and geriatric settings are prone to violence against nurses. A

survey of 284 nurses working in locked psychiatric units demonstrated a rate of verbal aggression of 0.6 incident per

nurse per week, and 0.19 incident per nurse per week for physical aggression. Episodes of violence were significantly

more common on the evening shift (compared with the day shift), and having more patients with personality disorders

was associated with higher rates of verbal and physical aggression.

An observational study[35] in an acute care geriatric ward targeted the behavioral cues that might serve as warning

signs for episodes of violence among elderly patients. Pacing around the bed universally preceded episodes of violent

behavior, and all patients who became violent had previously demonstrated shoving behavior.

Just as important as the number and features of reported incidents, however, is how nurses feel at work. Do they feel

safe, or are they frequently concerned about personal safety? Do they experience perceived threats, even if these

don’t materialize into violence? A study[36] in a pediatric ED found that 26% of nurses were concerned for their safety

at least weekly, and that the primary causes for their anxiety were patient or visitor agitation (with violence potential)

and weapons in the ED. Most nurses believed that having a greater presence of security personnel or local police

would increase their feelings of safety at work.

A new tool assesses perceptions of personal safety of nurses. Burchill[37] designed and pilot-tested a survey

instrument, the Personal Workplace Safety Instrument for Emergency Nurses (PWSI EN), which was found to have

high content validity for identifying the factors that make nurses feel safe or unsafe at work.

A Free Training Course in Workplace Violence

What prevents the risk for workplace violence from becoming a reality is often the steps taken by healthcare settings

and staff to prevent, prepare for, and respond to violence in the workplace. A key element of this preparation is

training in workplace violence geared toward nurses and other healthcare providers who are most likely to be victims

of such violence—education that would seem to be mandatory for nurses who work in high-risk settings. “But when

we spoke to nurses at healthcare conferences, many would tell us that they didn’t have access to violence training in

their work settings,” said Hartley.

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It was imperative to address this gap, and provide the tools and techniques that nurses need to prevent and manage

workplace violence. NIOSH collaborated with Vida Health Communications and other experts in healthcare violence

prevention to develop an online course called Workplace Violence Prevention for Nurses that awards free continuing

education credits (2.6 contact hours) upon completion of the course’s 13 modules. Course content was derived from

experts in the field of workplace violence and from the Occupational Safety and Health Administration’s guidelines for

the prevention of workplace violence in healthcare.[38]

The course content is applicable for any healthcare professional or student who desires an introduction to workplace

violence prevention strategies. For nurses who don’t have time to complete the course in one sitting, the course

applies “resume where you left off” technology.

Strengths of the course are hearing from nurses who have experienced violence in the workplace, and video case

studies involving violence in healthcare. Video case study scenarios include a psychiatric patient in the ED, an angry

husband on the postpartum unit, a death threat in home healthcare, a cognitively impaired patient in a long-term care

facility, and a bed-bound patient making inappropriate sexual advances. The case studies and personal stories will

resonate with nurses who have found themselves in similar situations, and perhaps wondered whether they could

have been handled differently. The vignettes inform viewers about the appropriate steps to take during and after

incidents of violence.

Using the crisis continuum as a model to describe how an individual progresses from normal stress and anxiety to a

loss of control, the course delineates intervention strategies, including verbal and nonverbal responses that can be

used to try and defuse tension and prevent the situation from escalating to violence. Nurses will learn about the

dynamics of power and control, and how these influence behavior not only in the aggressor, but in the nurse as well.

Is There an End to Workplace Violence?

Social and healthcare trends suggest that violence could continue to plague healthcare settings in the foreseeable

future. Our hospitals have become places for the sickest of the sick, intensifying anxiety and tension on the part of

friends and family members. Violence from the street spills over into urgent care facilities and trauma centers, and no

one is turned away.

ED crowding has not eased, so wait times continue to frustrate people seeking care. The burgeoning elderly

population is bringing with it an ever-expanding number of patients with dementia, and in many regions, access to

mental health care is insufficient. Although violence is not part of the job, dealing with potentially violent people is still

very real in healthcare.

Legislative solutions to workplace violence are being considered or have already passed in many states. Some of

these laws mandate establishment of workplace violence prevention programs in healthcare facilities, and others

increase penalties for those convicted of assaults on healthcare providers. However, many laws still pertain only to

specific settings, such as the ED. For example, Texas recently made it a third-degree felony to assault an ED nurse,

but it is still only a misdemeanor to assault a nurse elsewhere in a Texas hospital.[39] Except in the ED, it is a felony

to assault a nurse in only a handful of states. Clearly, we have more work to do.

To find out the laws in your state, visit the Emergency Nurses Association (ENA). The ENA also has extensive

workplace violence resources for nurses.

References

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13. Kvas A, Seljak J. Unreported workplace violence in nursing. Int Nurs Rev. 2014;61:344-351. Abstract

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15. Ünsal Atan S, Baysan Arabaci L, Sirin A, et al. Violence experienced by nurses at six university hospitals in

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16. Vezyridis P, Samoutis A, Mavrikiou PM. Workplace violence against clinicians in Cypriot emergency

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18. Khademloo M, Moonesi FS, Gholizade H. Health care violence and abuse towards nurses in hospitals in north

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19. ALBashtawy M. Workplace violence against nurses in emergency departments in Jordan. Int Nurs Rev.

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20. Abou-ElWafa HS, El-Gilany AH, Abd-El-Raouf SE, Abd-Elmouty SM, El-Sayed Hassan El-Sayed R.

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21. El Ghaziri M, Zhu S, Lipscomb J, Smith BA. Work schedule and client characteristics associated with

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22. Ogundipe KO, Etonyeaku AC, Adigun I, Ojo EO, Aladesanmi T, Taiwo JO, et al. Violence in the emergency

department: a multicentre survey of nurses’ perceptions in Nigeria. Emerg Med J. 2013;30:758-762. Abstract

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24. Zeng JY, An FR, Xiang YT, et al. Frequency and risk factors of workplace violence on psychiatric nurses and

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26. US Department of Labor, US Bureau of Labor Statistics. Table R4. Number of nonfatal occupational injuries

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perpetrated by hospital patients or patient visitors. J Emerg Nurs. 2014;40:218-228. Abstract

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Cite this article: Step Away From That Nurse! Violence in Healthcare Continues Unabated. Medscape. Nov 19, 2014.

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February 2019

www.nursingcenter.com

Workplace Incivility

Many health care professionals have experienced workplace incivility at some point in their

careers. We often think of the phrase “nurses eat their young,” and Frederick (2014) discovered

that due to incivility, “30% to 50% of all new nurses will leave their profession sometime during

their first 3 years of practice.” The Joint Commission (2016) discovered that “59% (of nurses)

experienced verbal abuse during a seven-day period.” These actions can contribute to

consequences ranging from work absenteeism to medical errors. Incivility should neither be

tolerated nor accepted in the workplace.

Definition

The American Nurses Association (ANA) (2019) has defined incivility as “one or more rude,
discourteous, or disrespectful actions that may or may not have a negative intent behind
them.” The ANA Position Statement (2015) on incivility states that nurses must make “a
commitment to – and accept responsibility for – establishing and promoting healthy
interpersonal relationships with one another.”

Forms of workplace incivility include (McNamara, 2012):

• Verbal abuse (i.e. gossiping, shouting, or swearing)

• Nonverbal abuse (i.e. eye rolling, making faces, excluding another from conversation)

• Passive-aggressive behavior (i.e. refusing to communicate, sabotaging a coworker)

• Bullying (i.e. accusing a coworker of someone else’s error, assigning unfavorable work,
expressing untrue critique)

Key Clinical Considerations and Outcomes

Incivility impacts patient care and any form of workplace incivility is unacceptable. The culture
of workplace incivility can lead to:

• Jeopardized patient safety

• Diminished teamwork

• Medication and/or medical errors

• Upsurge in sentinel events

• Increased patient mortality

• Reduced quality patient care

• Lower morale and productivity

• Absence from work

• Higher staff turnover

• Adverse effect on organization’s reputation

• Damage to the nurse/patient relationship

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February 2019
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Risk Factors (Torkelson, et. al, 2016)

Factors that can contribute to incivility include:

• Work environment changes

• Organization changes

• Lack of educational training and accountability

• Stressful patient workloads

• New technologies for communication

• Poor leadership or delegation

• Lack of teamwork

• Ineffective patient hand-offs

• Time constraints/deadlines

Steps to Address Incivility

Overall, organizations should develop a zero-tolerance policy for workplace incivility. These
behaviors should be well defined and outlined. The policy could include the penalty ensued for
each infraction (i.e. verbal warning for first offence, written warning for second offence, leave
without pay for third offence, and finally termination). The Human Resources department can
also be of assistance with developing a policy.

Other suggestions include:

• Refer to the American Organization of Nurse Executive (AONE) Guiding Principles on
Mitigating Violence in the Workplace (2014), created to assist leaders in developing
measures to diminish violence against health care professionals.

• Commit to the Joint Commission (2008) mandates which states, “The
hospital/organization has a code of conduct that defines acceptable and disruptive and
inappropriate behaviors. Leaders create and implement a process for managing
disruptive and inappropriate behaviors.”

• Develop educational programs for all members of the organization on this topic and
discuss ways to advance communication skills and enhance team-building.

• Utilize simulation to identify ways incivility can damage patient care and ways in which
the matter can be resolved.

• Develop a committee to battle this epidemic and help create solutions for the
organization at large.

Education

If workplace incivility is tolerated, negative behaviors continue and become commonplace in
the work environment. All team members in an organization should be educated on
appropriate professional behaviors that align with their code of conduct. Both nurse leaders
and staff must be able to identify it, take it seriously, and stop the behavior in its tracks.

http://www.nursingcenter.com/

February 2019
www.nursingcenter.com

References:

American Nurses Association (ANA). (2019). Violence, Incivility, & Bullying. Retrieved from https://www.nursingworld.org/practice-
policy/work-environment/violence-incivility-bullying/

American Nurses Association (ANA). (2015). American Nurses Association Position Statement on incivility, bullying, and workplace
violence. Retrieved from
https://www.nursingworld.org/~49d6e3/globalassets/practiceandpolicy/nursing-excellence/incivility-bullying-and-workplace-
violence–ana-position-statement

American Organization of Nurse Executive (AONE). (2014). Guiding Principles on Mitigating Violence in the Workplace. Retrieved
from http://www.aone.org/resources/mitigating-workplace-violence

Frederick, D. (2014). Bullying, mentoring, and patient care. AORN Journal, 99(5), 587-593. doi: 10.1016/j.aorn.2013.10.023

Kisner, T. (2018). Workplace incivility: How do you address it? Nursing2018, 48(6), 36-40. doi:
10.1097/01.NURSE.0000532746.88129.e9

McNamara, S.A. (2012). Incivility in nursing: Unsafe nurse, unsafe patients. AORN Journal, 95(4), 535-540. doi:
10.1016/j.aorn.2012.01.020

The Joint Commission. (2008). Behaviors that undermine a culture of safety. Sentinel Event Alert, 40. Retrieved from
https://www.jointcommission.org/assets/1/18/SEA_40.PDF

The Joint Commission. (2016). Bullying has no place in health. Quick Safety, 24. Retrieved from
https://www.jointcommission.org/assets/1/23/Quick_Safety_Issue_24_June_2016

Torkelson, E., Holm, K., Bäckström, M, & Schad, E. (2016). Factors contributing to the perpetration of workplace incivility: the
importance of organizational aspects and experiencing incivility from others. Work Stress, 30(2), 115-131. doi:
10.1080/02678373.2016.1175524

http://www.nursingcenter.com/

https://www.nursingworld.org/practice-policy/work-environment/violence-incivility-bullying/

https://www.nursingworld.org/~49d6e3/globalassets/practiceandpolicy/nursing-excellence/incivility-bullying-and-workplace-violence–ana-position-statement

http://www.aone.org/resources/mitigating-workplace-violence

https://www.jointcommission.org/assets/1/18/SEA_40.PDF

https://www.jointcommission.org/assets/1/23/Quick_Safety_Issue_24_June_2016

M A I N T A I N I N G A N D R E T A I N I N G A H E A L T H Y W O R K F O R C E

The role of aggressions suffered by healthcare workers as predictors

of burnout

Santiago Gascon, Michael P Leiter, Eva Andrés, Miguel A Santed, Joao P Pereira, Marı́a J Cunha,

Agustı́n Albesa, Jesus Montero-Marı́n, Javier Garcı́a-Campayo and Begoña Martı́nez-Jarreta

Aims and objectives. To examine the prevalence of aggression against healthcare professionals and to determine the possible

impact that violent episodes have on healthcare professionals in terms of loss of enthusiasm and involvement towards work. The

objective was to analyse the percentage of occupational assault against professionals’ aggression in different types of healthcare

services, differentiating between physical and verbal aggression as a possible variable in detecting burnout in doctors and

nursing professionals.

Background. Leiter and Maslach have explored a double process model of burnout not only based on exhaustion by overload,

but also based on personal and organisational value conflicts (community, rewards or values). Moreover, Whittington has

obtained conclusive results about the possible relationship between violence and burnout in mental health nurses.

Design. A retrospective study was performed in three hospitals and 22 primary care centres in Spain (n = 1Æ826).

Methods. Through different questionnaires, we have explored the relationship between aggression suffered by healthcare

workers and burnout.

Results. Eleven percent of respondents had been physically assaulted on at least one occasion, whilst 34Æ4% had suffered threats

and intimidation on at least one occasion and 36Æ6% had been subjected to insults. Both forms of violence, physical and non-

physical aggression, showed significant correlations with symptoms of burnout (emotional exhaustion, depersonalisation and

inefficacy).

Conclusions. The survey showed evidence of a double process: (1) by which excess workload helps predict burnout, and (2) by

which a mismatch in the congruence of values, or interpersonal conflict, contributes in a meaningful way to each of the

dimensions of burnout, adding overhead to the process of exhaustion–cynicism–lack of realisation.

Relevance to clinical practice. Studies indicate that health professionals are some of the most exposed to disorders steaming

from psychosocial risks and a high comorbidity: anxiety, depression, etc. There is a clear need for accurate instruments of

Authors: Santiago Gascon, PhD, Assistant Professor, Department of

Psychology, Zaragoza University, Teruel, Spain; Michael P Leiter,

PhD, Professor, Centre for Organisational and Development

Research, Acadia University, Wolfville, NS, Canada; Eva Andrés,

PhD, Researcher, CIBER Epidemiologı́a y Salud Pública, Unidad

Epidemiologı́a Clı́nica, Hospital 12 de Octubre, Madrid; Miguel A

Santed, PhD, Professor of Psychology and Dean of the Faculty of

Psychology, Spanish Distance University (UNED), Madrid; Joao P

Pereira, PhD, Assistant Professor, Instituto Superior de Maia, Castelo

da Maia; Marı́a J Cunha, PhD, Assistant Professor, Instituto Superior

de Maia, Castelo da Maia, Portugal; Agustı́n Albesa, PhD Student,

Psychologist and Lawyer, Department of Psychology, Zaragoza

University, Zaragoza; Jesus Montero-Marı́n, PhD, Assistant

Professor, Zaragoza University, Zaragoza; Javier Garcı́a-Campayo,

PhD, Professor, Department of Psychiatry Zaragoza University,

Zaragoza, Spain

Correspondence: Santiago Gascón, Assistant Professor, Facultad de

CC Sociales y Humanas (Psicologı́a) Ciudad Escolar s/n., 44003

Teruel, Spain. Telephone: +34 978645343.

E-mail: sgascon@unizar.es

This paper is based on the study by the University of Zaragoza,

whose basic data on the incidence of violence in health care and its

distribution among centres and facilities hospitals were already

published in Gascón S, Martı́nez-Jarreta B, González-Andrade F,

Santed MA, Casalod Y & Rueda MA (2009) Aggression towards

healthcare workers in Spain: a multicenter study to evaluate the

distribution of a growing violence among professionals, health

centers, and departments. International Journal of Occupational

and Environmental Health 15, 30–36. The levels of physical and

verbal violence in Spanish hospitals were reported in Gascón et al.

(2009), and this article (Gascón et al. 2012) aims to analyse the role

that these attacks could have on burnout.

� 2012 Blackwell Publishing Ltd
3120 Journal of Clinical Nursing, 22, 3120–3129, doi: 10.1111/j.1365-2702.2012.04255.x

evaluation to detect not only the burnout but also the areas that cause it. Professional exhaustion caused by aggression or other

factors can reflect a deterioration in the healthcare relationship.

Key words: aggression, burnout, community, healthcare relationship, healthcare workers, values

Accepted for publication: 12 May 2012

[Correction added on 15 August 2013, after first online publication: the authors, ‘Eva Andrés’, ‘Miguel A Santed’ and ‘Begoña Martı́nez-

Jarreta’, together with their affiliations were added. In addition, a statement that the paper is based on a study by the University of Zaragoza,

whose basic data and findings were previously published in Journal of Occupational and Environmental Health 15, 30–36 was inserted.

Previously omitted permissions to publish Tables 1, 3, 5 and 6 were also added to the relevant tables. Finally, acknowledgements of grants by the

Spanish Ministry of Labour & INHST (2008–2010): PSIPRV and the Department of Science and Education of the Aragonese Government

(Grupo Consolidado B44 & FONDO SOCIAL EUROPEO) were also inserted in the Acknowledgements section.]

Introduction

In Spain, burnout is not recognised as an occupational

disease (Royal Decree 1299/2006, Spanish Government

2006). However, many courts pass sentences that consider

burnout to be a work accident (Martı́nez de Viergol 2005).

The Spanish Law of Work Risk Prevention (Ley 31/1995

Prevención de Riesgos Laborales, Spanish Government 1995)

requires organisations to perform an evaluation of psycho-

social risks, but these laws have limited impact, partially

because of inconsistent enforcement of the regulations

(Gascón 2006). According to the Ministry of Work, the

population with the greatest psychosocial risk is that of

hospital workers (Gestal Otero 2003). It can seem somewhat

paradoxical that those who look after our health are those

who are most vulnerable to psychological disorders (Bruce

et al. 2002).

In the 1970s, burnout was described as a disorder

characterised by physical and emotional exhaustion, which

principally affected professions that demanded intense and

direct contact with others (Leiter & Schaufeli 1996). Later,

Maslach developed the MBI questionnaire (Maslach et al.

1996), which has been widely used to measure burnout as a

three-dimensional syndrome: exhaustion, depersonalisation

and lack of professional fulfilment (Leiter 2008). In 2000,

the same author along with Leiter centred their research in

the opposite dimensions of burnout: energy, implication and

efficacy, and the work-life areas that contribute to these

dimensions: workload, control, reward, community, fairness

and values (Maslach & Leiter 1997, Leiter & Maslach

2004a,b). Workload and control were derived from the

demand-control model of Karasek and Theorell (1990)

(Leiter & Schaufeli 1996, Leiter & Maslach 2004a,b).

Reward refers to the power of reinforcement to shape

behaviour. Community reflects the support of colleagues and

superiors as interpersonal conflicts, whilst fairness comes

from research on equity and social justice. Finally, value

reflects the cognitive-emotional power of job goals and

expectations. Each one of these areas includes various

aspects of organisational life. So community includes

positive and negative elements in interpersonal relationships

between colleagues and clients or patients; rewards include

aspects that provide intrinsic work satisfaction; and values

refer to the coherence between the individual’s values and

those of the organisation (Leiter & Maslach 2009, Leiter

et al. 2010).

The authors agree that overload and the control related to

exhaustion were not the only variable in burnout; the

aforementioned areas can erode the other dimensions and

generate cynicism and exhaustion (Leiter et al. 2008). As well

as exhaustion, the second aspect of burnout, implication,

includes ‘depersonalisation or cynicism’. With this dimension

reaching beyond the physical and emotional well-being of the

individual, the concept also expands its ability to concectarse

with the world. The third dimension includes the self-

perception that the worker has on their effectiveness and

performance at work.

This experience, maintained and becomes chronic over

time, erodes the vision of the worker on his ability to

transform and improve their working environment. These

three experiences, acting in an interdependent manner, form

what Leiter and Maslach considered a syndrome of three

dimensions (Laschinger & Finegan 2005, Leiter & Maslach

2009, Leiter et al. 2008).

As has been noted in several studies, a high level of

inconsistency in values, such as interpersonal conflicts, may

predict a significant proportion of the three dimensions of the

syndrome (Leiter & Maslach 2004a,b, Leiter et al. 2008). On

the other hand, in some professions such as health or

education, violent attacks on professionals from patients or

students have increased over the last years. Physical aggres-

sion, insults and threats can affect important areas such as

community, work rewards or a value conflict (Winstanley &

Whittington 2004, Gascón et al. 2008).

Maintaining and retaining a healthy workforce The role of aggressions suffered

� 2012 Blackwell Publishing Ltd
Journal of Clinical Nursing, 22, 3120–3129 3121

In recent years, some countries have developed zero

tolerance laws against these types of behaviours, but the prob-

lem continues to be considered a health issue of the first order

(Whittington 2002). In health, most of the published studies

have been centred on psychiatry because it is a source of

violence for many reasons (McKinnon & Cross 2008),

distinct from other areas in health, especially in the nursing

profession (Dunn et al. 2007). However, recent studies have

revealed that violence is not exclusive to only one area in

hospitals (Martı́nez-Jarreta et al. 2008). Psychiatry is not the

only place in which violence takes place; in large hospitals, it

is superseded in the emergency area (Gascón et al. 2009b).

The nursing profession suffers continuous physical

aggression

because of direct contact with the patient. Doctors and other

professionals are equally exposed, particularly to nonphysical

aggression (Martı́nez-Jarreta et al. 2008).

Aims and hypothesis

The aims of the study were to ascertain the weight that

aggression (physical, threats, verbal abuse, etc.) could have

when it comes to explaining burnout levels in the healthcare

sector and if it is produced in a similar way in doctors and

nursing professionals.

Health professionals are exposed to a wide variety of stress

sources: daily contact with sickness and death, attending

continuous urgent demands, uncertainty, the need to update

skills and knowledge, etc. (Gascón 2006). We consider that

violent episodes could contribute to exhaustion that manifests in

the variables of exhaustion, depersonalisation and inefficacy,

and the opposing dimensions: energy, involvement and efficacy.

Method

This was a retrospective study, using self-reporting, for the

purpose of researching levels of burnout and the experi-

ences of aggression and violence over the preceding twelve

months. The study was performed in three hospitals and 22

rural and urban primary care centres in Spain.

Participants

The survey included only permanent staff working continu-

ously in the same post for at least one year. A stratified

sample, proportional to the number of healthcare workers in

each centre, was studied. The questionnaires were distributed

in informative sessions carried out with groups of between 15

and 20 people, who were provided with information about

the study and how to answer the study questions. Partici-

pants returned the survey to boxes located in each of the

healthcare facilities. Of the 3000 surveys delivered, 2279

were returned and 1826 were used according to the criteria

of proportionality. The proportion, broken down by profes-

sion, was 603 doctors (33Æ02%), 878 nursing professionals

(48Æ08%), 144 administration staff (7Æ9%), 23 managers

(1Æ26%), 49 patient attendants (2Æ7%), 129 technical staff

and other professions (7Æ06%). The average age of the

participants was 41Æ84 years (SD 8Æ427); 64Æ2% were women

and 35Æ8% were men Table 1.

Instruments

The health workers completed a booklet containing the

following questionnaires:

• A demographic data record asked for personal, family and
workplace information.

• Maslach Burnout Inventory-General Survey (MBI, Mas-
lach et al. 1996). The 22 items are framed as statements of

job-related feelings (e.g. ‘I feel burned out from my work’;

‘I feel confident that I am effective at getting things done’)

and are rated on a 6-point frequency scale (ranging from

0 = ‘never’ to 6 = ‘daily’). Burnout is reflected by higher

Table 1 Number of participants and percent of workforce represented, by facility type and post (n = 1826)

Nurses

(%)

Doctors

(%)

Managers

(%)

Administration

(%)

Patient attendants

(%)

Others

(%)

Total participants

(%)

Large hospital 361 (20Æ0) 256 (21Æ5) 4 (13Æ0) 68 (27Æ4) 27 (0Æ6) 87 (25Æ7) 803 (43Æ9
Medium-sized hospital 169 (19Æ9) 91 (19Æ4) 14 (53Æ8) 22 (12Æ5) 16 (10Æ4) 31 (6Æ4) 343 (18Æ8)
Small hospital 157 (52Æ7) 50 (35Æ7) 2 (11Æ7) 14 (14Æ6) 6 (3Æ3) 11 (37Æ9) 240 (13Æ14)
Rural primary care 41 (7Æ6) 56 (11Æ7) 3 (33Æ3) 10 (22Æ8) 0 (0Æ0) 0 (0Æ0) 110 (6Æ02)
Urban primary care 150 (80Æ2) 150 (67Æ3) 0 (0Æ0) 30 (75Æ0) 0 (0Æ0) 0 (0Æ0) 330 (18Æ07)
Total 878 603 23 144 49 129 1826

Reproduced with permission from Maney Publishing from: Gascón S, Martı́nez-Jarreta B, González-

Andrade F, Santed MA, Casalod Y &

Rueda MA (2009) Aggression towards healthcare workers in Spain: a multicenter study to evaluate the distribution of a growing violence among

professionals, health centers, and departments. International Journal of Occupational and Environmental Health 15, 30–36. Available at: http://

www.maneypublishing.com/journals/oeh.

S Gascon et al.

� 2012 Blackwell Publishing Ltd
3122 Journal of Clinical Nursing, 22, 3120–3129

scores on exhaustion and depersonalisation/cynicism and

lower scores on efficacy.

• Areas of Work-life Scale (AWS, Leiter & Maslach 2004a)
comprises 45 items: 16 offered information about the

opposing dimensions to burnout (energy, involvement and

efficacy), and 29 items produce distinct scores for six areas

of work-life from a positive dimension – manageable

workload, control, reward, community, fairness and val-

ues (Leiter et al. 2010). The item measuring the perceived

congruence employed in different areas of their work is,

for example, ‘I have enough time to do what’s important

in my job’ (workload), or ‘Working here forces me to

compromise my values’ (values). Respondents indicate

their level of agreement on a five-point Likert-type scale

ranging from 1 (strongly disagree) to 5 (strongly agree).

The score is subsequently reversed negative items (Leiter

& Maslach 2004a). The AWS items were developed from

a series of staff surveys conducted by the Centre for

Organisational Research & Development (Leiter & Har-

vie 1998, Leiter et al. 2008) as a means of assessing the

constructs underlying their analysis of the six areas of

work-life. The scale has yielded a consistent factor struc-

ture across samples (Leiter et al. 2010).

• Aggression Questionnaire (Gascón et al. 2009b) contained
descriptions of various forms of aggression, in line with

what the Occupational Safety and Health Administration

(Cal. OSHA 1995) classifies as type II (Table 2), that is,

exercised by customers, users or patients, excluding

aggression not related to the workplace and aggression

by work colleagues or superiors. For each type a definition

was provided. The definitions, adopted from various

international organisations (Di Martino 2002), had previ-

ously been used by other authors (Winstanley & Whit-

tington 2004), included definition for physical aggression,

verbal threats, threatening behaviour and verbal abuse

(Table 3). Participants were asked whether they had any of

the listed types of violence and how often in the previous

12 months (regardless of the type or the resulting lesion),

using a Likert-type scale (0 = never; 1 = never, but has

been witnessed to it happening to others; 2 = on one

occasion; 3 = on two or more occasions; 4 = on more than

five occasions).

Ethical considerations

Authorisation from the Ethics Committee (CEICA, Aragon

Institute of Health Sciences – IACS) was obtained. Participa-

tion was voluntary and the professionals studied authorised

the inclusion of their data in the survey, by ticking a box. All

the answers were treated anonymously and the question-

naires were destroyed, after the data were collected.

Methodology

A series of correlation and regression analysis examined the

relationship between aggression on burnout dimensions, and

its relative contribution to the two process model proposed

by Leiter. Excessive workload predicted fatigue that, in turn,

predicted depersonalisation and low levels of efficacy.

Moreover, a mismatch in values contributed significantly to

a regression analysis predicting each of the dimensions of

burnout syndrome (Leiter et al. 2008).

Results

Survey shows high levels of physical and verbal abuse

against health professionals during the previous year

(Gascón et al. 2009a). Eleven per cent of respondents

Table 2 Types of violence investigated

Type of violence

in the workplace Definition

Type I Without relation to

work. Delinquency

Type II Carried out by clients,

users, patients and pupils

Type III Carried out by members of the

workforce: bosses, colleagues,

subordinates

Type IV Domestic violence, or personal

problems without relation to work

California Occupational Safety and Health Administration (OSHA

1995). Guidelines for workplace security.

Table 3 Definition of violent behaviour investigated

Aggression Definition

Physical

aggression

Intentional behaviour with the

use of physical force, producing

physical, sexual or psychological

damage: kicking, slapping, stabbing,

pushing and pulling, biting and pinching

Verbal threats or

threatening behaviour

The promise of using physical strength

or power, which produces the fear

of physical, sexual, psychological

damage or other negative consequences

Insults or slander Verbal behaviour which humiliates,

degrades or shows lack of respect

Reproduced with permission from John Wiley & Sons Ltd from:

Winstanley S & Whittington R (2004) Aggression towards health

care staff in a UK general hospital: variation among professions and

departments. Journal of Clinical Nursing 13, 3–10. Doi: 10.1111/

j.1365-2702.2004.00807.x.

Maintaining and retaining a healthy workforce The role of aggressions suffered

� 2012 Blackwell Publishing Ltd
Journal of Clinical Nursing, 22, 3120–3129 3123

(201) had been physically assaulted on at least one occasion,

5% (92) on more than one occasion, whilst 34Æ4% (628)

had suffered threats and intimidation on at least one

occasion and 23Æ8% (435) repeatedly, and 36Æ6% (668)

had been subjected to insults on at least one occasion and

24Æ3% (444) repeatedly.

The incidence was higher in large hospitals (Table 4), with

very high levels in services such as Accidents & Emergencies

and Psychiatry, with the incidences, respectively, of 48 and

26Æ9% for aggression, 82Æ1 and 64Æ1% for insults and 87Æ2

and 58Æ6% for threats (Table 5).

No statistically significant association was observed between

physical aggression and the victim¢s gender (v2 = 3Æ498;
p = 0Æ610), nor in relation to professional category

(v2 = 8Æ295; p = 0Æ141) (Table 6). This form of violence was

associated more with a specific type of centre and services. Both

forms of violence, physical and nonphysical aggression,

showed significant correlations with symptoms of burnout,

as much in the MBI dimensions (emotional exhaustion,

depersonalisation and inefficacy), as in the dimensions of

AWS (energy, involvement and efficacy) (Table 7).

By multiple regression analysis were analysed the resulting

patterns of the CFA further. The outcome variables were the

positive dimensions which Leiter & Maslach proposed for

burnout: energy, involvement and efficacy. For involvement/

cynicism, energy/exhaustion was entered as a predictor in

the first step; for efficacy, cynicism was entered as a

predictor in the first step, following a process model of

burnout. In the second step of these analyses, both values

and workload were permitted to enter in a stepwise fashion:

Table 4 Percentage of aggression by centre

Centre

Large hospital

(%)

Medium-sized

hospital (%)

Small hospital

(%)

Urban primary

health centres (%)

Rural primary health

centres

(%) v2 Meaning

Physical
aggression

21Æ9 21Æ7 9Æ5 17Æ4 11Æ3 26Æ435 p < 0Æ001

Insults 58Æ2 56Æ3 49Æ7 59Æ5 58Æ5 0Æ087 p = 0Æ100
Threats 55Æ7 56Æ3 43Æ2 57Æ0 58Æ5 0Æ120 p = 0Æ003

Table 5 Percentage of aggression by area

Service Surgical (%) Central (%) Medical (%) A&E (%) Psychiatry (%) Others (%) v2 Meaning

Physical
aggression

6Æ3 17Æ1 9Æ2 48Æ0 26Æ9 20Æ0 45Æ903 p < 0Æ001

Insults 62Æ3 25Æ0 47Æ1 82Æ1 64Æ6 25Æ0 19Æ995 p < 0Æ001 Threats 62Æ3 24Æ8 44Æ6 87Æ2 58Æ6 29Æ4 25Æ825 p < 0Æ001

Reproduced with permission from Maney Publishing from: Gascón S, Martı́nez-Jarreta B, González-Andrade F, Santed MA, Casalod Y &
Rueda MA (2009) Aggression towards healthcare workers in Spain: a multicenter study to evaluate the distribution of a growing violence among
professionals, health centers, and departments. International Journal of Occupational and Environmental Health 15, 30–36. Available at: http://
www.maneypublishing.com/journals/oeh.

Table 6 Percentage of aggression by post

POST

Admin

(%)

Patient

attendant (%)

Manager

(%)

Nurse

(%)

Doctor

(%)
Others
(%) v2 Meaning
Physical
aggression

7Æ5 18Æ2 10Æ0 17Æ0 19Æ4 11Æ1 8Æ295 p = 0Æ141

Insults 55Æ0 50Æ0 40Æ0 54Æ6 61Æ6 39Æ3 11Æ614 p = 0Æ040
Threats 42Æ5 39Æ1 65Æ0 49Æ9 60Æ7 35Æ7 22Æ678 p < 0Æ001

� 2012 Blackwell Publishing Ltd
3124 Journal of Clinical Nursing, 22, 3120–3129

either one or both of the predictors could enter the equation

if their coefficient was significant at the 0Æ05 level. For

energy, values and workload were entered in this fashion in

step 1 (Leiter et al. 2008).

The analysis confirms the relationships of six areas with

the three positive dimensions of burnout. The samples from

the doctors and nurses were analysed separately as they

were the two biggest groups and the most affected by

violent episodes.

In the doctor sample, the six areas and aggression episodes

(except physical assault) explained the 67% variance in

energy: workload (t = 11Æ892, p £ 0Æ001; B = 0Æ336), control
(t = 4Æ581, p £ 0Æ001; B = 0Æ149), reward (t = 5Æ615,
p £ 0Æ001; B = 0Æ184), community (t = 4Æ359, p £ 0Æ001;
B = 0Æ134), values (t = 4Æ407, p £ 0Æ001; B = 0Æ149), having
been insulted (t = 3Æ926, p = 0Æ02; B = 0Æ162) and having

suffered threats (t = 4Æ008, p £ 0Æ001; B = 0Æ107). Although
physical aggression was encountered in the doctor sample,

the results were not statistically significant. The energy

dimension in nurses was explained by workload (t = 9Æ322,

p £ 0Æ001; B = 0Æ349), reward (t = 4Æ135, p £ 0Æ001;
B = 0Æ153), values (t = 4Æ018, p £ 0Æ001; B = 0Æ140), having
been insulted (t = 3Æ826, p £ 0Æ001; B = 0Æ188) and having
suffered threats (t = 3Æ919, p = 0Æ03; B = 0Æ101).

In involvement, AWS and aggression explained 53% vari-

ance in the doctor sample: workload (t = 3Æ046, p = 0Æ002;

B = 3Æ046), control (t = 2Æ204, p = 0Æ02; B = 0Æ081), reward

(t = 5Æ925, p £ 0Æ001; B = 0Æ221), values (t = 4.912, p £ 0Æ001;
B = 0Æ188), physical aggression (t = 3.151, p = 0Æ05; B =

0Æ236), insults (t = 5Æ231, p = 0Æ001; B = 0Æ117) and threats

(t = 4Æ211, p £ 0Æ001; B = 0Æ193); in nurses: workload (t =
3Æ155, p £ 0Æ001; B = 0Æ077), reward (t = 4.672, p £ 0Æ001;
B = 0Æ333), values (t = 5.202, p = 0Æ001; B = 0Æ201), physical

aggression (t = 3Æ285, p £ 0Æ001; B = 0Æ138), insults
(t = 5Æ862, p = 0Æ002; B = 0Æ206) and threats (t = 2Æ383,

p £ 0Æ001; B = 0Æ200).
The 37% variance in efficacy by doctors was explained by

control (t = 3Æ147, p = 0Æ02; B = 0Æ125), reward (t = 4Æ275,

p £ 0Æ001; B = 0Æ172), community (t = 4Æ280, p £ 0Æ001;
B = 0Æ162), fairness (t = 2Æ548, p = 0Æ01; B = 0Æ104), values

(t = 1Æ463, p £ 0Æ001; B = 0Æ060), insults (t = 2Æ772,
p £ 0Æ001; B = 0Æ100) and threats (t = 1Æ907, p £ 0Æ001;
B = 0Æ095); for nurses: control (t = 3Æ478, p = 0Æ03;

B = 0Æ136), reward (t = 5Æ016, p £ 0Æ001; B = 0Æ228), values
(t = 2Æ367, p £ 0Æ001; B = 0Æ053), physical aggression
(t = 3Æ682, p £ 0Æ001; B = 0Æ049, insults (t = 3Æ160,
p £ 0Æ001; B = 0Æ098) and threats (t = 1Æ891, p = 0Æ002;
B = 0Æ086) Table 8.

The study confirmed the double process model of burnout

(Leiter et al. 2008). First, an excess charge weakens the

professional and prevents them regain their energy. On the

other hand, mismatches in the values and interpersonal

conflict, which include aggression, showed their ability to

predict the dimensions that conform to burnout syndrome.

The healthcare professionals reported moderately low

levels of workload and reported a negative evaluation of

the other five areas of work-life: rewards, community and

values that can be measured by the number, gravity and type

of aggression.

To ascertain the role of aggression in burnout, a

structural equation model (SEM) was conducted, using

the AWS and aggression levels, including the ten freed

error correlations. For the AWS, the analysis included three

indicators for each of the three subscales as defined in

Leiter et al. (2010), permitting the analysis to focus

primarily on the structural relationships among the con-

structs and to deemphasise the factor structure of the AWS

that has been established elsewhere (Leiter & Maslach

2004a,b). The mediated model produced an adequate fit

regarding the v2/df and RMSEA ( v2ð642Þ=1683Æ27,

p < 0Æ001; v2/df = 2Æ62; CFI = 0Æ895, RMSEA = 0Æ044).

The modification indices identified three areas of work-life

for which values did not fully mediate their relationships

with the burnout aspects: reward with exhaustion, com-

munity with cynicism and reward with efficacy. Adding

these three paths to a partially mediated model provided a

Table 7 Correlations (Rho Spearman) between burnout dimensions and types of aggression

MBI dimensions AWS dimensions

Emotional

exhaustion

Depersonalisation/

cynicism

Personal

accomplishment Energy Involvement

Efficacy

Physical aggression 0Æ109** 0Æ145** �0Æ015 �0Æ189** �0Æ172** �0Æ117**
Insults 0Æ167** 0Æ215** �0Æ137** �0Æ211** �0Æ273** �0Æ229**
Threats 0Æ198** 0Æ237** �0Æ178** �0Æ248** �0Æ307** �0Æ325**

n = 1Æ826.
**Correlations are significant at the 0Æ01 level (2 tailed).

Maintaining and retaining a healthy workforce The role of aggressions suffered

� 2012 Blackwell Publishing Ltd
Journal of Clinical Nursing, 22, 3120–3129 3125

better fit (v2ð639Þ=1588Æ90, p < 0Æ001; v 2/df=2Æ49; CFI =

0Æ904, RMSEA=0Æ042) that was a significant improvement

over the mediated model (v2ð3Þ = 94Æ37, p < 0Æ001) and

bringing the CFI to an adequate level. In the partially

mediated model, aggression demonstrated relationships

with the areas such as reward, community and fairness

and with values which demonstrates relationships with the

three dimensions of burnout (Fig. 1).

Table 8 Regression analysis: positive dimension of burnout. Criterion variables: dimensions opposed to burnout. Predictor variables: areas of

Work Life (Leiter & Maslach 2008)

Unstandardised

coefficients Standardised Coefficients

B SE b t Sig.

Dependent variable: energy

doctors n = 603

Constant 2,509 1,484 1,690 0,091

Workload 0,788 0,056 0,336 11,892 0,000

Control 0,624 0,119 0,149 4,581 0,000

Reward 0,690 0,100 0,184 5,615 0,000

Community 0,329 0,075 0,134 4,359 0,000

Values 0,851 0,096 0,149 4,407 0,000

Insults 0,462 0,058 0,162 3,926 0,020

Threats 0,395 0,112 0,107 4,008 0,000

Dependent variable: energy nurses

n = 878

Constant 3,491 1,422 1,571 0,077

Workload 0,908 0,056 0,349 9,322 0,000

Reward 0,890 0,100 0,153 4,135 0,000

Values 0,626 0,096 0,140 4,078 0,000

Insults 0,441 0,058 0,188 3,826 0,000

Threats 0,288 0,112 0,101 3,919 0,030

Dependent variable: involvement

doctors n = 603

Constant 6,276 0,746 8,412 0,000

Workload 0,186 0,028 0,098 3,046 0,002

Control 0,232 0,060 0,081 2,204 0,028

Reward 0,298 0,050 0,221 5,925 0,000

Values 0,436 0,048 0,188 4,912 0,000

Physical aggression 0,177 0,050 0,236 3,151 0,050

Insults 0,244 0,058 0,117 5,231 0,001

Threats 0,217 0,062 0,193 4,211 0,000

Dependent variable: involvement

nurses n = 878

Constant 5,387 0,648 7,329 0,020

Workload 0,197 0,180 0,077 3,155 0,000

Reward 0,301 0,043 0,333 4,672 0,000

Values 0,232 0,049 0,201 5,202 0,001

Community 0,130 0,054 0,194 4,117 0,000

Physical aggression 0,198 0,049 0,138 3,285 0,000

Insults 0,316 0,047 0,206 5,862 0,002

Threats 0,170 0,056 0,200 2,383 0,000

Dependent variable: efficacy

doctors n = 603

Constant 5,588 0,613 9,119 0,000

Control 0,255 0,049 0,125 3,147 0,002

Reward 0,198 0,041 0,172 4,275 0,000

Community 0,133 0,031 0,162 4,280 0,000

Fair 0,081 0,032 0,104 2,548 0,011

Values 0,258 0,040 0,060 1,463 0,000

Insults 0,166 0,033 0,100 2,272 0,001

Threats 0,290 0,051 0,095 1,907 0,000

Dependent variable: efficacy
nurses n = 878

Constant 4,779 0,707 8,924 0,053

Control 0,366 0,053 0,136 3,478 0,003

Reward 0,252 0,049 0,228 5,016 0,000

Values 0,199 0,046 0,053 2. 367 0,000

Physical aggression 0,201 0,050 0,049 3,682 0,001

Insults 0,206 0,041 0,098 3,160 0,000

Threats 0,290 0,049 0,086 1,891 0,002

S Gascon et al.

� 2012 Blackwell Publishing Ltd
3126 Journal of Clinical Nursing, 22, 3120–3129

It is very important to note that only 19Æ8% of healthcare

workers felt they were supported by management (Gascón

et al. 2009a). In multiple regression analyses, this variable

was seen to be a modulating factor of the psychological effect

of aggression (p = 0Æ001; odd ratio = �0Æ771) by emotional
exhaustion and (p = 0Æ001; odd ratio = �0Æ496) by deper-
sonalisation.

Discussion

As shown in other studies, health workers show a significant

risk of verbal and physical abuse by patients or their compan-

ions (Arimatsu et al. 2008). This is shown by the results in our

study, especially in very complex hospitals and in areas like

emergencies and psychiatry (Gascón et al. 2009b). Every

professional in contact with the public is exposed to physical

and verbal violence, which particularly affects nursing and

medical staff (Whittington 2002, Winstanley & Whittington

2004, McKinnon & Cross 2008). The latter, along with the

direction staff, is additionally exposed, because they must

make important decisions and threats become a way to

influence them (Martı́nez-Jarreta et al. 2008).

Violent episodes are one of the many risks health profes-

sionals have to face, and, as it has been shown in many studies

(Dunn et al. 2007, Arimatsu et al. 2008), they have clear

effects on physical and psychological symptomatology. This

could perhaps help explain why doctors and nurses are the two

professions with the highest psychiatric comorbidity (Bruce

et al. 2002, Löwe et al. 2003). The association between non-

physical violence and anxiety and symptoms of post-traumatic

stress disorder was seen to be statistically significant in several

studies (Whittington 2002, Gascón et al. 2009a), and others

have shown that the burnout syndrome, like depression,

anxiety and other disorders, affects health professionals (Löwe

et al. 2003, Findorff et al. 2004). In this survey, both forms of

violence showed a similar impact on burnout, as much in the

MBI dimensions, as in the dimensions of AWS.

The syndrome is not an ‘either/or’ question, but a slow and

insidious process. Thus, it can and must be observed in health

institutions to prevent it. The need is clear for accurate

instruments of evaluation to detect not only the burnout but

also the areas that cause it.

In addition to providing a good instrument for measuring

the burnout syndrome (MBI), in 2000 Leiter and Maslach

created a questionnaire measuring the opposing dimensions

of the syndrome, as well as the causes that may contribute to

its development (Leiter & Maslach 2004a,b). The authors

developed the theory of the double process of burnout, which

explains that a worker can get burnt out not only because of

an excess of workload, but also because of conflicting values,

interpersonal problems in the work place, absence of reward

and lack of equity (Leiter et al. 2008).

This study confirms the model of two processes of

burnout: a evident process of workload–exhaustion and

another that shows the relationship that a mismatch in

values and interpersonal conflict has on the three dimensions

of burnout syndrome. Aggression has shown an important

contribution in the value congruence and the energy and

involvement dimensions. So that confirms that burnout is

more than an exhaustion syndrome (Leiter & Schaufeli

1996).

As various authors have pointed out, it is necessary to

develop strategies focused on minimising the occurrence of

violent episodes in health care and to minimise their possible

impact, when they occur, by deploying both a programme of

prevention and a programme of medical, psychological and

legal assistance (McKinnon & Cross 2008). Managing

violence with safe and effective protocols should be a goal

for hospital¢s managers and a necessary skill for profession-
als, particularly for mental health nurses (Dunn et al. 2007),

emergency specialists (Martı́nez-Jarreta et al. 2008) and

other healthcare professionals.

On the basis of the results of this study, our team have

proposed prevention protocol, which includes medical and

Manageable workload

InvolvementAggression

Reward

Fairnes

Community

Efficacy

Outcomes

Energy

Values

–.05

–.59

–.47

.42–.75

.17

.16

–.62

.29

.14

.16

.38
.53

Figure 1 Casual model coefficients:

aggression – areas work-life (n = 1826).

Maintaining and retaining a healthy workforce The role of aggressions suffered

� 2012 Blackwell Publishing Ltd
Journal of Clinical Nursing, 22, 3120–3129 3127

legal counsel as well as psychological support for the victims.

We are currently working on intervention models in which

the professionals themselves have proposed measures of

change to be implemented in hospitals with the support of

management.

In view of the results, we cannot establish a cause–effect

relationship between aggression and burnout. The variables

studied could contribute to a maladaptive cycle in which the

violence contributes to exhaustion and cynicism, but we can

also consider that these events can promote aggressive behav-

iour of a patient who does not feel well served. Further studies

are needed to establish the contribution of intervention

programmes: both violence prevention and in providing

professional skills to manage potentially conflicting situations.

Acknowledgements

This study was conducted with support from the Ministry of

Health of Spain and the IIISASO (International Research of

Social, Environmental and Occupational Health Institute).

In addition, this work was supported by grants from the

Spanish Ministry of Labour & INHST (2008–2010): PSIPRV

and the Department of Science and Education of the

Aragonese Government (Grupo Consolidado B44 &

FONDO SOCIAL EUROPEO).

Conflict of interest

None.

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Rehabilitation Nursing • Vol. 35, No. 5 • September/October 2010 177

Rehabilitation NURSING

KEY WORDS

health care

workplace violence

Rehabilitation NURSING

Workplace violence is a problem plaguing all
employers and employees who work in healthcare
settings. Physical violence can result in physical
injuries or, in extreme cases, death of a worker
(Bergen, Chen, Warner, & Fingerhut, 2008; Hart-
ley, Biddle, & Jenkins, 2005). Verbal violence is
another form of workplace aggression and has been
linked to negative consequences, including anxiety,
depression, and stress (Spector, Coulter, Stockwell,
& Matz, 2007). Violence affects workers from all
disciplines in the healthcare field. DuHart (2001)
reported that both physicians and nurses were
victims of workplace violence—the rate of physical
violence committed against physicians was 16.2 per
1,000 workers and against nurses it was 21.9 per
1,000 workers. Other healthcare workers, including
patient care assistants, were assaulted at a rate of
8.5 per 1,000 workers (DuHart). The purpose of this
article is to describe the risk factors and protective
strategies associated with workplace violence per-
petrated by patients and visitors against healthcare
workers.

Risk Factors for Workplace Violence
in Healthcare Settings
Healthcare workers are exposed to a variety of fac-
tors that increase their risk for physical and verbal
workplace violence from patients and visitors. The
National Institute for Occupational Safety and
Health (NIOSH, 1996) reported several risk fac-
tors, including working with the public, handling

money, transporting or delivering passengers or
items, working with people who are more likely
to be violent, working in the community setting
or high crime areas, working during nighttime
or early morning hours, guarding valuables, and
working alone. Perpetrator, worker, and setting and
environmental risk factors are described below.

Perpetrator Risk Factors
Mental health disorders (such as dementia, schizo-
phrenia, anxiety, acute stress reaction, suicidal ide-
ation, and alcohol and drug intoxication [American
Medical Association, 2007]) have often been identi-
fied in people who have committed workplace
violence (Catlette, 2005; Gates, Fitzwater, & Succop,
2003; Gates, Ross, & McQueen, 2006; Gillespie,
2008; James, Madeley, & Dove, 2006; Lee, Gerber-
ich, Waller, Anderson, & McGovern, 1999). Patient
dementia was identified as a factor in 87% of physi-
cal assaults on nursing home assistants (Gates et
al., 2003). Mandiracioglu and Cam (2006) found
that patient dementia was linked to 11% of violent
events while other psychiatric diseases were linked
to another 25%. Gates and colleagues’ study (2003)
may have reported an increased rate of violence
committed by patients with dementia because a
larger percentage of nursing home residents had
dementia in their particular study sites.

Using the Staff Observation Aggression Scale–
Revised, Almvik, Rasmussen, and Woods (2006)
studied male and female patients with Alzheimer ’s

This article describes the risk factors and protective strategies associated with workplace violence perpetrated by patients
and visitors against healthcare workers. Perpetrator risk factors for patients and visitors in healthcare settings include
mental health disorders, drug or alcohol use, inability to deal with situational crises, possession of weapons, and being
a victim of violence. Worker risk factors are gender, age, years of experience, hours worked, marital status, and previous
workplace violence training. Setting and environmental risk factors for experiencing workplace violence include time of
day and presence of security cameras. Protective strategies for combating the negative consequences of workplace violence
include carrying a telephone, practicing self-defense, instructing perpetrators to stop being violent, self- and social support,
and limiting interactions with potential or known perpetrators of violence. Workplace violence is a serious and growing
problem that affects all healthcare professionals. Strategies are needed to prevent workplace violence and manage the nega-
tive consequences experienced by healthcare workers following violent events.

Rehabilitation NURSING

Workplace Violence in
Healthcare Settings: Risk
Factors and Protective
Strategies
Gordon Lee Gillespie, PhD RN PHCNS-BC • Donna M. Gates, EdD RN FAAN • Margaret
Miller, EdD CNS RN • Patricia Kunz Howard, PhD RN CEN FAEN

Free Ce OFFerING
FOr ArN MeMbers

Log on to www.
rehabnurse.org and visit
the Education page for
more details

RNJ_10 SEPT OCT.indd 177 8/2/10 2:16:40 PM

178 Rehabilitation Nursing • Vol. 35, No. 5 • September/October 2010

Workplace Violence in Healthcare Settings: Risk Factors and
Protective Strategies

disease and the severity of physical violence they
committed against their healthcare workers. Alm-
vik and colleagues determined that the severity of
physical violence perpetrated by male patients was
significantly greater than violence perpetrated by fe-
male patients (p < .01). This may be because men are more likely to enact physical violence and women are more likely to enact verbal violence. In addition, men are physically capable of causing more bodily injury when hitting, striking, or pushing healthcare workers compared with women who commit physi- cal violence.

Another leading perpetrator risk factor for ver-
bal or physical violence is the influence of drugs or
alcohol (Catlette, 2005; Crilly, Chaboyer, & Creedy,
2004; Chaplin, McGeorge, & Lelliott, 2006; Gates et
al., 2006; Gerberich et al., 2004; Gillespie, 2008; James
et al., 2006; Keely, 2002; Keough, Schlomer, & Bollen-
berg, 2003; Kowalenko, Walters, Khare, & Comptom,
2005; Lin & Liu, 2005). In one study, 35% of healthcare
workers believed that the violent perpetrator was us-
ing drugs or alcohol before the violent event (DuHart,
2001). In a second study, participants believed that
perpetrators were under the influence of drugs or
alcohol in 50% of all verbally violent events and 96%
of all physically violent events (Crilly et al.).

Patients’ and visitors’ inability to deal with a crisis
situation is another perpetrator risk factor for workplace
violence (Catlette, 2005; Gates et al., 2006; Gillespie,
2008). For example, the stress experienced during an
emergency department (ED) visit may create a crisis
during which patients or visitors are no longer able to
deal with a situation as they normally would (Broer-
ing, Campbell, Favand, Galvin, & Holleran, 2007). This
stress may increase verbal or physical violence. Crises
can occur when there are disagreements with the medi-
cal plan, denials of a service or request, conflicts with
healthcare workers, excessive waiting times for as-
sessments and interventions, inability to focus beyond
oneself, perceptions that a healthcare worker is rude or
uncaring, grief over the death of a child, and inability to
change a healthcare outcome (Badger & Mullan, 2004;
Catlette; Committee on Pediatric Emergency Medicine,
1997; Ergün & Karadakovan, 2005; Gates et al., 2006;
Gillespie; James et al., 2006; Keely, 2002; Lin & Liu, 2005;
McAneney & Shaw, 1994).

Gerberich and colleagues (2004) reported that the
gender and age of a perpetrator are factors associated
with violence against healthcare workers. They found
that the majority of verbally violent perpetrators were
men (73%, n = 1,594) age 35–65 (54%, n = 1,186). Phys-
ical violence was most often enacted by men (59%,
n = 386) and people 66 years or older (64%, n = 423).
Children 17 years old and younger represented the
smallest group of perpetrators of physical violence

(5.3%, n = 35) and verbal violence (5.7%, n = 122).
James and colleagues (2006) reported similar findings
for gender when studying safety event reports from a
hospital in the United Kingdom. Males (66%, n = 97)
and patients between 16 and 35 years (55%, n = 82)
were most likely to be perpetrators of violence.

The sheer volume of weapons being brought into
healthcare settings today may increase the potential
for violence against healthcare workers. Peek-Asa,
Cubbin, and Hubbell (2002) noted that in 2000, pa-
tients were more likely to carry guns and knives
when being treated in a healthcare setting than in
1990. Sixteen years ago, McAneney and Shaw (1994)
found that more than one-half of pediatric ED direc-
tors had already started confiscating weapons from
pediatric patients. DuHart (2001) reported that 11%
of perpetrators used a weapon during the commis-
sion of violent events against healthcare workers.
Although some EDs instituted a weapon-screening
system in triage, patients who arrived by ambulance
were not routinely checked for the presence of weap-
ons (McAneney & Shaw).

Being a victim of violence, particularly when the
violence resulted from a firearm injury, is a perpe-
trator factor significantly linked to enacting violence
against others (Bingenheimer, Brennan, & Earls,
2005; Cunningham et al., 2009). Bingenheimer and
colleagues tracked 1,517 Chicago adolescents longi-
tudinally and found that adolescents who had seen
or been victims of violence were significantly more
likely than adolescents with no exposure to violence
to self-report impulsivity (p < .0001) and aggression toward others (p < .0001) and commit violent offenses (p < .0001). These behaviors increase the likelihood that the patient who is a victim of violence will be violent toward the healthcare workers providing his or her care.

Worker Risk Factors
Certain characteristics have been found to increase
the risk of workers being targets of workplace
violence in the healthcare setting, including the
worker’s gender, age, years of experience, hours
worked, marital status, and previous workplace
violence training.

Contradictory evidence about whether a worker’s
gender poses a risk for being verbally or physically
assaulted by patients and visitors exists. Ayranci, Ye-
nilmez, Balci, and Kaptanoglu (2006) ascertained that
women experienced a higher percentage of verbal
and physical violence compared with men, although
the difference was not significant. However, most
researchers reported that men experienced work-
place violence significantly more often than women
(Anderson & Parish, 2003; Camerino, Estryn-Behar,

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Rehabilitation Nursing • Vol. 35, No. 5 • September/October 2010 179

Conway, van Der Heijdend, & Hasselhorn, 2008;
Ferrinho et al., 2003; Hegney, Plank, & Parker, 2003;
Hegney, Eley, Plank, Buikstra, & Parker, 2006; James
et al., 2006; Miedema, Easley, Fortin, Hamilton, &
Tatemichi, 2009; Thomas et al., 2006). In contrast,
Tolhurst, Baker, and colleagues (2003) determined
that there was no significant difference in the overall
frequency of verbally and physically violent events
between groups of male and female physicians; how-
ever, the percentage of men who experienced at least
one violent event during the preceding 12 months
was greater than the percentage of women. Privitera,
Weisman, Cerulli, Tu, and Groman (2005) noted that
the gender of clinical and nonclinical mental health
workers did not significantly affect the number of
verbally or physically violent events they endured.
However, a greater percentage of female physicians
had a fear of future violence compared with male
physicians (Tolhurst, Talbot, et al., 2003).

Healthcare workers younger than 40 years old
were most frequently the victims of violent events
(Ayranci et al., 2006). Researchers also observed that
older workers experience significantly less violence
than younger workers (Camerino et al., 2008; Hegney
et al., 2003, 2006; Lawoko, Soares, & Nolan, 2004;
Thomas et al., 2006). In addition, Gates, Fitzwater,
Telintelo, Succop, and Sommers (2002) researched
how a nursing home assistant’s age affected the inci-
dence of violence. As the age of caregivers increased,
the frequency of violence committed against them
decreased. Gates and colleagues posited that this rela-
tionship may be a result of older nursing home assis-
tants being more adaptable, patient, and empathetic
and moving more slowly during interactions with the
elderly. As with gender, not all research findings for
age were consistent. In contrast, Ergün and Karada-
kovan (2005) provided evidence that nurses report-
ing physical violence were significantly older than
nurses who denied an event of physical violence. An-
derson and Parish (2003) did not detect a relationship
between age and the occurrence of violence among
Hispanic nurses, but this may be due to them study-
ing lifetime incidence for workplace violence versus
a limited 12-month period for workplace violence.
The lifetime incidence of violence will generally be
greater for older workers as compared with younger
workers because the accumulative number of violent
events will increase as each year passes. In contrast,
when studying the number of violent events during
a 12-month period, the number of violent events per
person per year will likely be less for older workers.

Ergün and Karadakovan’s (2005) research showed
a significant and positive accumulative relationship
between the number of violent events and years of
nursing experience. Anderson and Parish (2003)

found no relationship between years of experience
and the occurrence of violence; however, their study
was limited to Hispanic nurses working in Texas. It is
possible that there may be geographical or ethnic dif-
ferences between Hispanic Texan nurses and nurses
from other cultures, states, or countries. And although
the accumulated number of violent events spanning
a career may increase with each successive year, the
incidence per each successive year may decrease. This
would explain why nurses with less work experience
report a greater number of violent events per year
but more experienced nurses accrue a greater life-
time number of violent events. In contrast to Ergün
and Karadakovan, Kowalenko and colleagues (2005)
determined that less experienced physicians incurred
violence more often than more experienced physi-
cians. The difference in findings may be attributed
to differences in data analysis; for example, Ergün
and Karadakovan studied cumulative incidence of
violence compared with Kowalenko and colleagues
who studied violent incidences during a 12-month
period.

Other healthcare worker characteristics associ-
ated with an increased risk of workplace violence
include the number of hours worked per week
and marital status. Part-time employees experi-
enced reduced risk of physical assault compared
with full-time employees (OR = 0.35, p < .001; Thomas et al., 2006), even though part-time em- ployees experienced a significant (p < .01) increase in violent events from 2001 to 2004 (Hegney et al., 2006). Lin and Liu’s study (2005) reported that un- married workers were significantly (p < .01) more likely to experience workplace violence compared

Key Practice Points
1. Being a victim of violence, particularly when the violence

resulted from a firearm injury, is significantly linked to
enacting violence against others.

2. The odds of being physically assaulted at work are reduced
when there is a security presence, video cameras present,
and organizational policies that address assault prevention
and repeat violent offenders.

3. Social support reduces the negative physical and
psychological symptoms and negative attitude toward work
following violent events.

4. The foremost strategy for violence is an effective workplace
violence program focused on preventing violence before it
occurs, safely managing violent events, and coping with the
psychological consequences that occur after violent events.

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180 Rehabilitation Nursing • Vol. 35, No. 5 • September/October 2010

Workplace Violence in Healthcare Settings: Risk Factors and
Protective Strategies

with married workers, which may be the result of
married workers being accustomed to working with
others toward a mutual understanding or agreement.

Evidence about whether violence-prevention train-
ing reduces the risk of workplace violence is contradic-
tory. One group of researchers found that participants
who had not attended violence-prevention training
were at greater risk for workplace violence than work-
ers who did attend training (Ergün & Karadakovan,
2005). However, Nachreiner and colleagues (2005) re-
ported that violence training increased the likelihood
of being a victim of physical violence. Specific training
components that contributed to an increase in the risk
for experiencing violence included managing assault-
ive or violent patients (OR = 1.551; p = .03), reporting
work-related physical assault (OR = 1.639, p > 0.05),
practicing self-defense (OR = 1.393, p > .05), and rec-
ognizing risk factors for violence (OR = 1.314, p > .05).
Lee and colleagues (1999) stated that the relative risks
for physical violence against a nurse increased when
the nurse had received assault-prevention training
with a previous employer (RR = 2.57), had completed
training with his or her current employer (RR = 4.64),
and his or her employer accepted assault as being
part of the job (RR = 8.14). Data from these studies
defy logic. The researchers provided four possible
explanations for the contradiction. First, workplace
violence-prevention training may only be provided
in settings in which violence is more common (Lee
et al.). Second, the training may increase awareness
of the need to report violent events (Lee et al.). Third,
victims of violence may be more likely to recall previ-
ous training (Lee et al.). Fourth, workers who receive
violence-prevention training may be more likely to
intervene during violent events, whereas their un-
trained counterparts may be more likely to remain
passive (Nachreiner et al.).

Identifying the healthcare worker most at risk
for experiencing violent events based on his or her
characteristics is difficult because research findings
in the literature are inconsistent. Many researchers
have concluded that men are more likely to be vic-
tims of workplace violence (Anderson & Parish, 2003;
Camerino, Estryn-Behar, Conway, van Der Heijdend,
& Hasselhorn, 2008; Ferrinho et al., 2003; Hegney,
Plank, & Parker, 2003; Hegney, Eley, Plank, Buikstra,
& Parker, 2006; James et al., 2006; Miedema, Easley,
Fortin, Hamilton, & Tatemichi, 2009; Thomas et al.,
2006); however, it is possible that women are more
frequently the targets of violence, but men become
victims of workplace violence because they intervene.
Older, more experienced workers report a greater
number of violent events throughout their work life,
but younger, less experienced workers report a great-
er number of recent violent events. Availability of

violence-prevention training has also been associated
with increased risks for workplace violence. It is not
known whether employers identified violent work
environments after implementing violence training
programs or whether the programs were implement-
ed as a result of workplace violence events. Evidence
has consistently shown, however, that all workers are
at risk for some degree of workplace violence despite
their gender, age, years of work experience, and avail-
ability of training opportunities.

Setting and Environmental Risk Factors
Environmental factors that have been shown to
reduce the risk of physical assault against healthcare
professionals include controlled access to patient
areas, reduced wait times, security presence, and
escorting workers to their vehicles (Catlette, 2005;
Crilly et al., 2004; Gates et al., 2006; Gerberich et al.,
2005; Gillespie, 2008; Lee et al., 1999; Nachreiner
et al., 2005). Lee and colleagues and Ayranci and
colleagues (2006) provided evidence that the likeli-
hood of a nurse being physically assaulted at work
was reduced when there was a security presence,
video monitors, and organizational policies that
addressed assault prevention and repeat violent
offenders. In contrast, Gerberich and colleagues
ascertained that nurses’ risks for experiencing
physical assault were actually increased when
employers used video monitors, metal detectors,
or panic buttons. Gerberich and colleagues did not
provide an explanation for this finding, but it may
be the result of an increased awareness of violence
leading to increased reporting or an increase in
employer efforts to make environmental changes
for improved worker safety in response to violent
events.

Other researchers have identified that violence is
more likely to occur during certain times of the day.
Ergün and Karadakovan (2005) found that 70% of
violent events took place between 4 pm and 8 am,
which was supported by other researchers (AbuAl-
Rub, Khalifa, & Habbib, 2007; Crilly et al., 2004;
Gates et al., 2006; Gillespie, 2008). Increased rates of
violence during evening and nighttime hours may
be attributed to the types and conditions of patients
who seek treatment during later hours, such as in-
toxication and injuries due to violence (McAneney
& Shaw, 1994). Almvik and colleagues (2006) further
stated that violent events in long-term care were most
likely to occur during daytime and evening hours
with few events occurring during nighttime hours.
This difference may be due to the setting; long-term
care patients who are aggressive may be asleep dur-
ing nighttime hours and, therefore, unable to enact
violence against others.

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Rehabilitation Nursing • Vol. 35, No. 5 • September/October 2010 181

Protective Strategies for Workplace
Violence
When violent events occur, some healthcare pro-
fessionals are likely to experience negative conse-
quences, which can be minimized by protective
strategies. The literature identified personal pro-
tection as an effective protective strategy against
violence. In a sample of 116 Iraqi hospital nurses
who reported physical violence, 27% (n = 13) took
no action and 49% (n = 24) attempted to defend
themselves during the event (AbuAlRub et al.,
2007). Self-defense may be an effective strategy to
prevent injury until help arrives or escape from
the patient room is possible. Gerberich and col-
leagues (2005) determined that hospital nurses
who carried some form of personal protection or a
personal cellular telephone had a greatly reduced
odds ratio for being assault compared to those who
did not (.30 to 1); however, when nurses used an
employer’s cellular telephone or personal alarm
system, the odds ratio for assault did not decrease
(1.03 to 1). This discrepancy may reflect employees’
lack of knowledge about how to use the employer’s
equipment at the time of the event. Employees who
carried some form of personal protection may have
decreased their risk of a violent event because they
were more aware of the potential for violence and
relied on themselves for protection, and those who
used employers’ measures relied on the employer
for protection. Tolhurst, Talbot, and colleagues
(2003) found that 15% (n = 47) of rural physicians
started carrying a cellular telephone with them to
use in the event of workplace violence. Kowalenko
and colleagues (2005) reported that 16% (n = 27)
of Michigan physicians in their study carried a
concealed weapon as a form of protection because
they feared workplace violence or had previously
experienced a violent event.

Healthcare workers also exhibited a no-tolerance
policy as a strategy for reducing risk for violent
events. Findorff, McGovern, Wall, and Gerberich
(2005) randomly sampled 4,166 hospital employees
and found that some instructed perpetrators to stop
being verbally violent. These workers were more
than three times as likely to report the violence com-
pared to workers who did not tell the perpetrator to
stop. Even though Findorff and colleagues did not
report whether the perpetrator stopped the verbal
assault when instructed to by workers, the simple
act of setting a limit on unacceptable behavior may
have helped protect the worker against long-term,
violence-related stress.

After experiencing a violent event, some health-
care workers protected themselves against the nega-
tive effects with self-support (Gillespie, 2008). Catlette

(2005) interviewed eight trauma nurses about their
experiences with workplace violence. Nurses dis-
cussed using self-support techniques such as humor,
talking about the experience, and taking advantage
of leisure time, but did not report whether the partici-
pants believed that the interventions were effective
(Catlette). During qualitative interviews of pediatric
emergency workers, Gillespie discovered that drink-
ing a cold beverage and taking a short break helped
decrease stress following a violent event.

Researchers identified that support from other
people after a violent event was another strategy for
protecting against negative effects. Schat and Kello-
way (2003) found that support (e.g., showing con-
cern, listening to the victim’s story) from coworkers
and managers had a positive effect on study partici-
pants from a Canadian healthcare system who were
primarily nurses, patient care assistants, laboratory
and technical assistants, counselors, and social work-
ers. The support reduced their negative physical and
psychological symptoms and negative attitudes to-
ward their work. Gillespie (2008) concluded that an
informal debriefing should occur during the same
shift as the violent event to prevent future intrusive
thoughts from affecting the worker’s sleep.

Although Schat and Kelloway (2003) identified
social support as an effective strategy for protecting
against the negative consequences of violent events,
they also found that the support had no effect on a
worker ’s fear of future workplace violence. The re-
searchers concluded that to increase the social sup-
port of a worker, this fear must be addressed through
interventions such as formal debriefings or profes-
sional counseling sessions.

Another protective strategy identified in the litera-
ture included changing current practices to promote
personal safety. Magin, Adams, Ireland, Heaney, and
Darab (2005) found that general practitioner physi-
cians who worked in urban settings documented their
destinations after hours, checked in with spouses at
predetermined periods, and stopped making house
calls to patients with whom they were unfamiliar
or who lived in areas of low socioeconomic status.
Female physicians in the study were more likely to
take their spouses with them during home visits. Tol-
hurst, Talbot, and colleagues (2003) stated that 30%
of general practitioners made similar changes to their
after-hours practices based on the risk of workplace
violence. Physicians’ most significant change was
instructing patients whom they didn’t know or who
had a history of perpetrating violence to seek health
care with a different provider when they requested
to be seen after hours. In fact, 5% of the physicians
stopped making home visits altogether.

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182 Rehabilitation Nursing • Vol. 35, No. 5 • September/October 2010

Summary
Perpetrator, worker, and setting and environmental
factors have been associated with risk for workplace
violence. Perpetrator factors that increased the risk of
violence were gender, age, the possession of weapons,
mental disorders (including dementia), and the influ-
ence of drugs or alcohol. Worker factors that were
associated with a decreased risk of violence were age,
years of experience, hours worked, and marital status.
However, evidence related to the effect of gender and
workplace violence training on the risk of workers
experiencing an assault was conflicting. Setting and
environmental factors that were related to increased
risk for workplace violence (though not definitively)
included time of the day (daytime versus evening
and nighttime hours) and changes to the environment
such as the presence of security systems or cameras.

Employees in healthcare settings cannot prevent all
violent events; however, they can use several strate-
gies to protect themselves against the negative conse-
quences of workplace violence. Strategies for workers
include carrying concealed weapons or personal cel-
lular telephones to defend against the consequences of
physical violence, instructing perpetrators to stop their
violent acts, engaging in self-care to cope with a violent
event, receiving support from colleagues and employ-
ers, and limiting the availability of after-hours care or
care for patients who have a history of violence.

Implications for Rehabilitation Nursing
Both rehabilitation nurses and organizations must
implement strategies to reduce the risks associated
with workplace violence. All verbally and physi-
cally abusive threatening and harmful acts should
be considered violent, despite the intent or cogni-
tive accountability of the perpetrator. Even when
perpetrators are cognitively impaired patients,
violent acts can be physically debilitating or psy-
chologically harmful to healthcare professionals
(Badger & Mullan, 2004; Brock, Gurekas, Gelinas,
& Rollin, 2009; Rose & Cleary, 2007). The strategies
depicted in this section are universal regardless of
the patient’s intent or cognitive accountability for
committing a violent act.

The foremost protective strategy is implementing
an effective workplace violence-deterrant program
focused on prevention, safe management, and help-
ing victims cope with the psychological consequences.
Violence-prevention training should take place when
workers are hired and should be supplemented with
annual or semiannual updates. Educational compo-
nents may include a description of factors related to
violent events, such as patients or visitors experiencing
a situational crisis or the influence of drugs or alcohol.
Additional training components may include training

specific to rehabilitation settings, such as identifying
patients with signs of substance abuse withdrawal and
intervening early or establishing new physical limi-
tations (e.g., inability to perform normal activities of
daily living). Developing case studies based on real
violent events reported by rehabilitation healthcare
workers would increase the personal relevance of ed-
ucational programs. Case studies allow rehabilitation
workers to discuss why the patient or visitor escalated
to verbal or physical violence and what actions could
yield a more positive outcome.

Special strategies can be used for patients who are
victims of violence (e.g., patients suffering injuries
from gunshots, stabbings, and gang assaults) includ-
ing limited visitor access and using a pseudonym for
patients. These two strategies may be necessary to
prevent exposure to the same stressor that caused the
original violent event. Using a pseudonym to regis-
ter patients in hospital or rehabilitation settings may
help reduce the likelihood that they will be disturbed
by people who are capable of provoking violent be-
havior in these patients. Limiting visitor access to two
designated individuals (e.g., spouse, parents) reduces
the chance that a room full of anxious and stressed
visitors will resort to workplace violence.

It is important for healthcare workers to recognize
that the reported risks for violence are not all inclusive
and that every patient and visitor should be consid-
ered potentially violent. When initial signs of violence
are identified, interventions should be implemented
immediately, especially de-escalation techniques.
These include actively listening to the patient or visi-
tor, attempting to identify concerns and reasons for
the escalation, honestly answering patient and visitor
questions, allowing access to visitors who may have a
calming effect on the patient, and providing comfort
measures (e.g., warm blankets, beverages, snacks, and
medications for pain, anxiety, and agitation control).

Organizational policies addressing workplace vi-
olence should include plans for how to address find-
ing a weapon on a patient or visitor. For example,
employees should calmly leave the patient’s room,
notify security personnel that a weapon has been
discovered, and make no attempts to remove the
weapon from the patient. Homecare workers should
instruct their patients to remove all firearms from
the premises before home visits or keep firearms in
a lock box with the ammunition removed and stored
separately. Care plans should indicate that a firearm
is on the premises. Healthcare workers should be
informed about and adhere to the organizational
policies and provide input about how to keep the
policies up to date. Experienced workers can men-
tor and guide less experienced colleagues in com-
munication and care delivery strategies that may

Workplace Violence in Healthcare Settings: Risk Factors and
Protective Strategies

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Rehabilitation Nursing • Vol. 35, No. 5 • September/October 2010 183

calm patients and visitors, diffuse tense situations,
and discourage the use or presence of weapons.

Limited empirical evidence is available for
protective strategies that are implemented after a
workplace violent event has already occurred. It is
important for all healthcare professionals to recognize
the signs of stress, in patients as well as themselves.
Those experiencing stress should request or be offered
a break from the patient-care environment. A plan for
dealing with workplace violence, the means to call
for help (e.g., personal alarms, cellular telephones,
radios), and knowledge about how to use protective
technology (e.g., activating a personal alarm) are also
important. It may not be feasible to limit hours of
service (e.g., inpatient rehabilitation units or on-call
homecare services) or refuse patients; however, or-
ganizations should implement plans, including flag-
ging charts and specifically soliciting this information
during shift-change reports and new referral intake
processes, to identify patients who have a history of
violence. Patients who have had a violent encounter
with a particular healthcare professional should be re-
assigned to someone else when feasible. This may not
be possible when the caregiver (e.g., registered nurse,
physical therapist) is the only provider within a geo-
graphic area that includes the patient’s residence. To
provide additional protection, healthcare professionals
should communicate their location at regular intervals
with a unit coordinator or home care office, with a plan
to be activated if they fail to do so. Home care workers
may need a chaperone or to conduct home care visits
in pairs to increase personal safety.

Conclusion
A review of the literature revealed a number of
risks and protective strategies associated with
violent events committed by patients and visitors
against healthcare workers in the workplace. Work-
place violence is a serious and growing problem in
today’s healthcare settings and affects all employees.
Although protective strategies were identified to
reduce negative consequences of violent events,
it is important that researchers conduct rigorous
studies to determine which factors—and in which
combinations—provide the greatest protection. It is
important that employers and employees recognize
that the only strategy proven to prevent the negative
consequences of workplace violence is an effective
violence-prevention program. Healthcare profession-
als have a right to be safe while on duty and should
be proactive in collaborating with their employers
to create that safe work environment (Occupational
Safety and Health Administration, 2004).

About the Authors
Gordon Lee Gillespie, PhD RN PHCNS-BC, is an assistant
professor at University of Cincinnati, College of Nursing
in Cincinnati, OH. Please address correspondence to him at
gordon.gillespie@uc.edu.

Donna M. Gates, EdD RN FAAN, is a professor at University
of Cincinnati, College of Nursing in Cincinnati, OH.

Margaret Miller, EdD CNS RN, is professor emeritus at Uni-
versity of Cincinnati, College of Nursing in Cincinnati, OH.

Patricia Kunz Howard, PhD RN CEN FAEN, is operations
manager at UK Chandler Hospital Emergency & Trauma Ser-
vices in Lexington, KY.

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Workplace Violence in Healthcare Settings: Risk Factors and
Protective Strategies

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Jennifer Becher, MSN, APRN, is Acute Care Nurse Practitioner, University of Nebraska Medical
Center, College of Nursing, Omaha, NE.

Constance Visovsky, PhD, RN, ACNP-BC, is Associate Dean, Student Affairs and Community
Engagement, University of South Florida, College of Nursing, Tampa, FL.

Horizontal Violence in Nursing

T
o achieve high-quality
care, professional team-
work among nursing staff
is imperative. Teamwork is

a critical element for achievement of
positive patient outcomes (Joint
Commission, 2008). Teams achieve
success through a shared vision, a
positive attitude, and respect for each
other (Phillips, 2009). Conversely,
negative workplace relationships can
disrupt team performance, creating a
work environment that can lead to
burnout, increased staff turnover,
and poor patient outcomes. Acts of
aggression by one nurse colleague
against another is termed horizontal
violence (HV) (Longo & Sherman,
2007). In this article, the occurrence
of horizontal violence in nursing
will be described, and strategies for
preventing and ameliorating its
effects will be provided.

What Is Horizontal
Violence?

Horizontal or lateral violence has
been described broadly as any
unwanted abuse or hostility within
the workplace (Stanley, Martin,
Nemeth, Michel, & Welton, 2007).
Thobaben (2007) defined horizontal
violence as “hostile, aggressive, and
harmful behavior by a nurse or group
of nurses toward a coworker or group
of nurses via attitudes, actions, words
and/or behaviors” (p. 82). Horizontal
violence is characterized by the pres-
ence of a series of undermining inci-
dents over time, as opposed to one
isolated conflict in the workplace
(Jackson, Firtko, & Edenborough,
2007). This repeated conflict makes
HV overwhelming, leading to symp-
toms of depression and even post-
traumatic stress syndrome in the vic-

tim. Horizontal violence tends to be
covert, hard to discern, or discover;
the victim thus has difficulty in seek-
ing assistance within the job setting.
Horizontal violence also has been
portrayed as an intergroup conflict
with elements of overt and hidden
hostility (Joint Commission, 2008).
Members of the nursing profession
have been described as an oppressed
group, having mostly female mem-
bers. Oppression theory suggests that
powerlessness, lack of control over
the working environment, and sub-
sequent low self-esteem contribute to
the development of HV within the
nursing profession (St-Pierre &
Holmes, 2008). However, this fails to
address the notion that HV occurs
across many professions, and encom-
passes individual, social, and organi-
zational characteristics (Wilson,
Diedrich, Phelps, & Choi, 2011).

Horizontal violence that results in
repeated acts of aggression toward
colleagues also is known as work-
place bullying (Longo & Sherman,
2007). Vessey, Demarco, and DiFazio
(2010) defined personality character-
istics of a bully to be one who publi-
cally or privately demeans another
employee. They suggested the bully’s

behavior is deliberate, with the
intention to cause physical or psy-
chological stress to the victim.
Intimidating behaviors of individu-
als engaged in bullying often are
present across the lifespan. Bullies
may rally support from others as a
means of endorsing their behavior.
This group support provides an audi-
ence that reinforces aggression, fur-
ther isolating the victim and
enabling the bully to operate and
extend his or her influence (Randle,
Stevenson, & Grayling, 2007).

More recently, the specific behav-
iors that constitute HV have been
described (Center for American
Nurses, 2008; Edwards & O’Connell,
2007; Vessey et al., 2010). These
behaviors may include criticizing,
intimidation, blaming, fighting
among co-workers, refusing to lend
assistance, public humiliation, with-
holding behavior, and undermining
the efforts of targeted individuals
(Edwards & O’Connell, 2007). Other
actions displayed by a perpetrator
may include name calling, threaten-
ing, gossiping, isolating, ignoring,
unreasonable assignments, using
silence, and making observable
physical expression such as eye

Professional Practice

Jennifer Becher
Constance Visovsky

Horizontal or lateral violence is considered an act of aggression among
nursing professionals. Horizontal violence creates a negative work envi-
ronment impairing teamwork and compromising patient care. The
effects of horizontal violence and strategies for prevention and man-
agement are addressed.

July-August 2012 • Vol. 21/No. 4 211

Horizontal Violence in Nursing

rolling (Gerardi & Connell, 2007;
Thobaben, 2007). The more mini-
mal, rude behaviors may be ignored,
thus contributing to the underre-
porting of horizontal violence
(Araujo & Sofield, 2011).

Horizontal violence occurs most
frequently among peer group workers
within the professional structure. A
study by Wilson and colleagues
(2011) found 61.1% of surveyed nurs-
es reported HV observed between co-
workers on their unit. Horizontal vio-
lence can extend to persons who
work closely with nurses, including
physicians (49.1%) and staffing
supervisors (26.9%). However, HV is
not confined to those in lateral posi-
tions. Horizontal violence has been
known to extend from the nurse lead-
ership to the staff they supervise.
Stagg, Sheridan, Jones, and Speroni
(2011) reported 28% of nurse respon-
dents had been bullied by a member
of leadership.

Incidence and Prevalence
of Horizontal Violence

The actual incidence and preva-
lence of horizontal violence in nurs-
ing are relatively unknown, as HV
often is unrecognized and underre-
ported. However, recent investiga-
tions assert that horizontal violence
is fairly widespread at 65%-80% of
nurses surveyed (Stagg et al., 2011;
Stanley et al., 2007; Vessey, Demarco,
Gaffney, & Budin, 2009; Wilson et
al., 2011). Johnson and Rea (2009)
examined HV among 249 nurse
members of the Washington State
Emergency Nurses Association. They
concluded 27.3% had experienced
bullying in the workplace, with 18
nurses in the sample reporting expe-
riencing two negative acts daily or
weekly and as many as 50 nurses
experiencing three or more negative
acts on a daily or weekly basis. In
another study of nursing students in
Australia, approximately 50% of stu-
dents experienced horizontal vio-
lence during their clinical rotations
(Curtis, Bowen, & Reid, 2007).
Students also reported feeling power-
less and humiliated as they began to
assimilate these behaviors into the
workplace. A survey of junior nurs-
ing students shows horizontal vio-

lence occurs as early as the first inter-
action of a student with professional
nurses in a clinical setting (Thomas
& Burk, 2009). New graduate nurses
experiencing HV reported a higher
level of absenteeism and considered
leaving the profession altogether
(Curtis et al., 2007).

What Are the Effects of
Horizontal Violence?

Horizontal violence damages the
dignity of the individual and ulti-
mately is detrimental to the profes-
sion, as aggression arises from co-
workers who should be providing
guidance and support (Saltzberg,
2011). Horizontal violence has spe-
cial implications for student and
newly graduated nurses, who have
many questions and require profes-
sional development to reach their
full potential. New graduate nurses
experiencing HV may have difficulty
attaining success due to an environ-
ment of continual conflict (Khalil,
2009; Thomas & Burk, 2009).
Horizontal violence affects the entire
health care team due to an ever-
widening rift between employees or
groups of employees. Horizontal vio-
lence causes a wide array of effects
that extend from the victim to the
health care team and ultimately, to
the patient (Joint Commission,
2008; Roche, Diers, Duffield, &
Catling-Paull, 2010). The victim of
HV may experience low self-esteem,
anxiety, depression, and sleeping dis-
orders (Thobaben, 2007). Many
nurses who have experienced HV
subsequently have considered leav-
ing or have left the profession, con-
tributing to the national nursing
shortage (Huntington et al., 2011).
Powerlessness, anger, and work
absences have been reported with
repeated acts of bullying. In addition
to the psychological effects of bully-
ing, HV suicidal behaviors have also
been reported (Vessey et al., 2010).
The Joint Commission (2008) indi-
cated poor communication is a main
factor in sentinel events affecting
health care teams and compromis-
ing patient safety. When essential
information related to patient care is
omitted as an act of HV, the victim-
ized nurse is in a poor position to

care for the patient and patient safe-
ty is compromised. The subsequent
cost to patient, family, and institu-
tion from compromised care, as well
as the potential legal action, can be
staggering. Over half the events of
horizontal violence are never report-
ed. Even with “no retaliation” poli-
cies in place, victims may not know
the appropriate steps to take to
report HV (Stagg et al., 2011; Vessey
et al., 2010). The financial cost of
HV has been estimated to be
$30,000-$100,000 per year for each
individual. Costs are incurred as a
result of work absenteeism, treat-
ment for depression and anxiety,
decreased work performance, and
increased turnover (Gerardi &
Connell, 2007). Pendry (2007) esti-
mated the cost of replacing one spe-
cialty nurse (e.g., ICU or surgical)
may exceed $145,000.

What Can Be Done to
Deter Horizontal Violence?

The American Nurses Association
Code of Ethics (ANA, 2001) directs
the behaviors expected from profes-
sional nurses. Standard 6 of this code
indicates professional nurses are
responsible for attaining and main-
taining work environments consis-
tent with professional values. The
Center for American Nurses (2008)
issued a position statement with an
associated example policy for stan-
dards of healthy work environment.
These standards apply to all levels of
nursing practice, from the chief
nursing officer to the individual staff
nurse. The current health care envi-
ronment poses many challenges that
contribute to horizontal violence.
Poor staffing, increased patient acu-
ity, and reduced resources combine
to increase stress and conflict
(Huntington et al., 2011).

Nurse leaders are in a unique posi-
tion to prevent and eliminate HV by
providing resources in terms of sup-
port and education. Leaders who
demonstrate trusting behaviors allow
staff to feel supported. Providing
resources to decrease job stress and
anxiety can prepare nurses to care for
their patients (Longo & Sherman,
2007). Nurse leaders should support
staff by providing constructive, real-

July-August 2012 • Vol. 21/No. 4212

time feedback when needed (Randle
et al., 2007). Providing ample oppor-
tunities for education and profes-
sional development is important in
planning to prevent or eliminate HV
in the workplace (Cleary, Hunt,
Walter, & Robertson, 2009). Nurse
educators should be an integral part
of the training process as they under-
stand the specific hospital system
and how to navigate it (Longo, Dean,
Norris, Wexner, & Kent, 2011).
Formal education sessions defining
HV, direct approaches to modifying
behavior, and review of conse-
quences are needed (Edwards &
O’Connell, 2007). Stagg and co-
authors (2011) offered predeter-
mined responses based on the type of
HV through formal education ses-
sions. Using cognitive rehearsal,
nurses were better prepared for a
response to HV when it occurred.
Informal education including posters
and fliers enable reinforcement after
classes (Cleary et al., 2009).

Nurse leaders must hold them-
selves and their peers accountable for
modeling acceptable professional
behavior. When unprofessional be –
haviors are displayed, a corrective
plan must be instituted. Once prob-
lems related to HV have been identi-
fied within an organization, a plan
must be initiated to change the cul-
ture that supports acts of HV. In
approaching complaints or situations
involving HV, nurse leaders must
maintain an objective stance and
assess all related facts (Cleary et al.,
2009). They must be familiar with
organizational policies directly relat-
ed to HV (Vessey et al., 2010). Most
importantly, they must be prepared
to enforce policies with appropriate
disciplinary action when acts of HV
threaten the integrity of the work-
place. Managers must participate in
the same HV education as their
employees to keep themselves alert
for its occurrence (Stagg et al., 2011).

To facilitate discussion of preven-
tion and elimination of HV in the
workplace, focus groups can be held
to identify areas for improvement
and initiate an action plan (Longo &
Smith, 2011; Maxfield, Grenny,
McMillan, Patterson, & Switzler,
2005). The focus group can aid in
developing a philosophy and code of

conduct applicable to every employ-
ee within the institution. The
American Association of Critical-
Care Nurses developed a resource to
assist health care leaders in dis-
cussing means for decreasing errors,
improving quality of care, decreasing
nursing turnover, and improving
productivity (Maxfield et al., 2005).
Four topics within this document are
related directly to horizontal vio-
lence, including lack of support,
poor teamwork, disrespectful behav-
ior, and micromanagement of
employees. These four topics could
form the basis of focus group discus-
sions, or provide a forum for nurse
managers to address expectations for
behavior with new employees.

Nursing staff must take a role in
combating horizontal violence.
Nurses must know the policies that
govern professional conduct in the
workplace (Maxfield et al., 2005),
and feel empowered to take actions
against HV. Strategies for empower-
ment consist of confronting and
teambuilding (Kupperschmidt, 2006),
mentorship programs (Latham,
Hogan, & Ringl, 2008), and cognitive
rehearsal (Stagg et al., 2011). Maxfield
and colleagues (2005) found only 5%-
15% of nurses would confront a col-
league concerning unprofessional
behaviors. Only 10% of nurses felt
comfortable enough to confront a co-
worker displaying HV (Wilson et al.,
2011). Most nurses believed it either
was not possible or not their responsi-
bility to confront issues concerning
unprofessional conduct. Co-worker
support was cited as a reason to stay
in the current position even when
stress levels were high (Huntington
et al., 2011). Student nurses and new
nurse graduates are at particular risk
for loss to the profession if they
experience horizontal violence. In
the process of undergoing role tran-
sitions and increased role expecta-
tions, they experience increased
stress in the workplace. Students and
new graduate nurses need to be
exposed to professional behaviors
that deter horizontal violence in the
workplace (Thomas & Burk, 2009).
Preceptors assigned to new graduates
must understand the negative
impact of HV on new professionals.
Preceptors of students and new grad-

uates should model professional
behavior with the intent of provid-
ing guidance and support (King-
Jones, 2011). Preceptors also must be
knowledgeable in methods to deter
horizontal violence among staff, and
exhibit professional behavior that
builds trust and teamwork. Providing
new graduates with a mentor located
on another unit may offer a resource
within the organization for coping
with potential issues of HV. Some
essential mentoring responsibilities
include counseling, teaching, protect-
ing, coaching, and sponsorship (Bally,
2007).

Victims of Horizontal
Violence

At an institution where horizon-
tal violence has not been addressed,
steps can be taken by nurses who are
experiencing bullying behavior.
First, they should maintain a healthy
view of self, so as not to personalize
attacks of HV (Kerfoot, 2007). In sit-
uations of HV, talking with a trusted
colleague or friend may be helpful
(Randle et al., 2007). Talking about
situations of HV helps the individual
confirm if circumstances do consti-
tute acts of horizontal violence, and
may establish a witness to the
events. Counseling may be indicated
to support the emotional needs of
the victim and should be sought rel-
atively quickly to avoid unnecessary
emotional turmoil. Counseling ses-
sions may help the victim to learn to
be assertive in situations of horizon-
tal violence. Journaling, another
strategy to address HV, can serve dual
purposes. First, keeping a detailed
journal will help the victim main-
tain a timeline of events (Cleary et
al., 2009). Second, journaling may
provide an emotional outlet for the
psychological distress associated
with HV. Good documentation
requires a list of witnesses to the
accounts and all notes, texts, or
emails from the perpetrator also be
kept as part of the journal (Cleary et
al., 2009; Edwards & O’Connell,
2007).

Exhibiting assertive behavior at
the time of the event is considered
an acceptable response to HV behav-
iors. If possible, actions that consti-
tute bullying should be confronted

Professional Practice

July-August 2012 • Vol. 21/No. 4 213

Horizontal Violence in Nursing

during or immediately following the
incident. Conversation must remain
both empathic and factual (Randle
et al., 2007). The victim must insist
that all bullying behavior cease, and
be specific about the behavior exhib-
ited without talking about the way
the behavior made him or her feel.
Only factual events that constituted
the horizontal violence should be
discussed, with a focus on the specif-
ic unprofessional behaviors and the
return to a more professional, colle-
gial environment (Cleary et al.,
2009).

Reporting HV through proper
channels is encouraged. Severe inci-
dents, such as public slander, physi-
cal abuse, or criminal offenses,
require reporting through the facili-
ty’s proper channels. The victim
should not retaliate toward a bully in
order to avoid escalating the inci-
dent into legal action against the
original victim (Kerfoot, 2007).
Nurse leaders must work with staff to
distinguish subjective from factual
information, and assure policies per-
taining to the horizontal violence
are followed and appropriate disci-
plinary action is taken. If a nurse
manager is the perpetrator of the HV,
staff in the human resources depart-
ment can serve as a resource for
employees. All employees involved
in situations of HV need to be kept
abreast of the situation and know
that addressing HV may take several
weeks (Cleary et al., 2009).

Conclusion
Horizontal violence can exist to

some extent in any institution, with
the potential to disrupt the integrity
of the nursing profession and ulti-
mately compromise patient care
(Joint Commission, 2008). Failing to
address HV can discourage students
and new graduate nurses, who may
leave the profession (Thomas &
Burk, 2009). Nurses must acknowl-
edge the existence of horizontal vio-
lence, confront horizontal violence,
and take appropriate actions to miti-
gate it (Vessey et al., 2010). A policy
of zero tolerance for any sort of hor-
izontal violence in the workplace is
the goal (Center for American
Nurses, 2008).

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Issues

PAGE 15 July 2014 Volume 22, No 1.

Issues
Kechi Iheduru-Anderson

Educating senior nursing students to stop lateral
violence in nursing
Lateral violence (LV) in nursing has
been well documented for many
years, sometimes referred to as
workplace bullying or horizontal
violence.

LV in nursing is an unacceptable, disrup-
tive and inappropriate behaviour involving
nurses either overtly or covertly aiming
their dissatisfaction with work to others
who are in an equal or lesser position
(Coursey et al., 2013). ‘Nurses eating their
young’ is the expression used by many
to describe the feeling new nurses have
when faced by behaviours that signify
LV as they enter the nursing workforce.

Lateral violence can create a very hostile
environment. It has been shown to psycho-
logically, emotionally and physically affect
those who experience it. The experience
of lateral violence has also been shown
to have negative impact on work perfor-
mance, negative impact on the patient
care and outcome, and sometimes lead to
nurses’ attrition. Healthy work environment
has been recognised as an important factor
contributing to the recruitment and reten-
tion of nurses. The retention of new nurses
is essential for the future supply of nurses
to be able to sustain high quality patient
care across all healthcare setting.

For new nurses who are already facing the
challenges of transitioning from students
to nurses in a stressful profession and in
challenging work environments, “the first
months of practice can be chaotic, painful,
and traumatic, fostering feelings of isolation,
vulnerability, and uncertainty” (Lavoie-Trem-
blay et al, 2008). Adding the burden of LV
can have devastating effect on their wellbe-
ing, career, and their work performance,
hence jeopardising patients’ welfare.

There is a plethora of nursing literature
with examples of prevalence of LV. It has
been shown that LV education strength-
ens coping skills for nurses who deal with
disruptive behaviour.

There are many examples where student
nurses witness LV or bullying and may
be bullied by staff nurses during clinical
rotations themselves. New nurses have
described being afraid to ask questions

of more experienced nurses because of the
generalised climate of workplace bullying
and hostility. Lateral violence stops newly
licensed nurses from asking questions,
seeking validation of known knowledge,
and leave them feeling like outsiders. It
also stops them from learning and gaining
the knowledge necessary to develop the
competence in clinical practice (Griffin,
2004). This type of situation could lead
to these inexperienced nurses making
mistakes. Coursey et al, (2013) suggested
that nursing education include instruction
on how to deal with lateral violence.

Providing an educational forum on lateral
violence for student nurses at the begin-
ning of the senior year is essential for
raising consciousness on this issue. This
program utilised cognitive rehearsal as
described by Griffin (2004) as an effec-
tive educational method to address LV. To
address the problem of LV and to mitigate
its effect, senior nursing students in an
associate degree program at a private com-
munity college receive a four hour seminar
with scenarios, case studies and role play-
ing on lateral violence. They are asked to
read two articles about lateral violence in
preparation for the seminar.

One of the ways to prevent and stop LV in
the nursing profession is to create aware-
ness and break the silence. The goal of this
seminar is to illuminate the mechanisms
of LV and create awareness to this ongo-
ing problem. It is hoped that with better
students’ understanding of the practices
and expressions of LV in the workplace, the
cycle of LV can be decreased or eliminated
as they enter professional nursing prac-
tice. This will also allow the students to
consider their own practice and reactions
to LV activity as they enter the profession.
The choice was made to educate student
nurses to recognise, speak up and prevent
perpetuation of LV in nursing.

Senior nursing students were instructed on
aspects of lateral violence. They were given
laminated cards with some of the most
common forms of LV and the responses
to lateral violence scenarios suggested by
Griffin (2004). During role play and simula-
tions, students observe and respond to be-

haviours indicative of LV. The also practice
how to deal with bullying and bullies. They
responded to fifteen multiple choice pre
and post-tests on LV and wrote a reflective
journal detailing their feelings and thoughts
during the activities. Most of the students
described the experience as empowering.
Most of them were especially happy with
the opportunity to role play and respond
to scenarios. The goal is to continue with
this project and invite the students back
to participate in focus groups six to 18
months after graduation to explore and
ask questions about LV and the effect their
educational exercise have on them.

Nurses have professional and ethical obli-
gation to stop LV and to put an end to the
phrase ‘nurses eat their young.’ We need
to support our young, create a positive
image for this noble profession. Let us stop
participating in these oppressive behav-
iours that manifest into LV in the nursing
practice. Don’t keep quiet or look the other
way when you witness these activities that
allow LV to flourish.

Senior nursing students who are getting
ready to join the nursing workforce is an
ideal place to start addressing this viral issue.
Senior nursing students represent the
potential for the future of nursing.

Lavoie-Tremblay, M., Wright, D., Desforges,
N., G´elinas, C., Marchionni, C., & Drevniok,
U. (2008). Creating a Healthy Workplace for
New-Generation Nurses. Journal of Nursing
Scholarship, 40(3), 290–297.

Coursey, J., Rodriguez, R., Dieckmann, L.,
& Austin, P. (2013). Successful implementa-
tion of policies addressing lateral violence.
AORN Journal, 97(1), 101-109. doi:10.1016/j.
aorn.2012.09.010

Griffin, M. (2004). Teaching cognitive rehearsal
as a shield for lateral violence: an intervention
for newly licensed nurses. Journal of Continuing
Education in Nursing, 35(6), 257-263.

Kechi Iheduru-Anderson is a professor
of nursing at Quincy College, Quincy
Massachusetts and Adjunct faculty at
Regis College Weston and Laboure
College Milton Massachusetts.

Copyright of Australian Nursing & Midwifery Journal is the property of Australian Nursing
& Midwifery Federation and its content may not be copied or emailed to multiple sites or
posted to a listserv without the copyright holder’s express written permission. However, users
may print, download, or email articles for individual use.

B) Horizontal & Lateral Violence Case Study:

Use the corresponding article on Horizontal Violence to help answer the questions to the following

two

case studies. Remember that all assignments need to be in APA format with a title page and running header AND must include your OWN researched professional reference that is cited within your responses.

A new grad nurse. Janet K. was a new graduate on the nursing unit. She was very excited to have passed her NCLEX exams and was very pleasant and enthusiastic about starting work on her busy unit. The nurses on the unit knew that a particular physician, Dr. M. followed a specific routine for making rounds. Janet K. had several of his patients that day but was unaware of his routine. The nurses on the unit decided not to share that information with her as they know that Dr. M would be arriving soon with certain expectations of the nurse who would be making rounds with him. They decided that this would be a “fun” way to “take her down a notch, and wipe that silly grin off her face.” Dr. M. arrived and Janet had not prepared his patients or his charts for his rounds. He began to berate her loudly in front of everyone at the nurse’s station. The other nurses, retreated to the back in the medicine room and all smirked & chuckled while Janet K. stood red-faced and endured his tongue lashing. Janet K. learned to hide her enthusiasm for nursing and stayed on the unit long enough to be oriented and to complete the required six months before transferring to another unit in the hospital.

1) What examples of horizontal violence are seen in this case study? Describe them.

2) What are some of the effects that horizontal violence can have on a nursing unit or healthcare institution?

3) Based on the article and the recommendations that it provides, how would you advise nurse Janet to handle each of the situations?

After each incident, the nurse manager asked Sylvia’s coworkers to speak to her about the offensive behavior. In each case, when the coworker told Sylvia she didn’t appreciate her behavior, Sylvia denied it had occurred and ended the conversation. The nurse manager has also spoken with Sylvia three times in the past year about her behavior, and this has led to temporary improvements. A few months after these discussions, however, the negative, abrasive, and aggressive behavior that Sylvia’s peers have described resurfaced.

In the last four weeks, Sylvia’s colleagues have reported several negative interactions.

* A physician’s assistant complained that Sylvia made a comment about a patient’s “disgusting” body odor within earshot of the patient.

* A nurse coworker described how Sylvia yelled at her for asking too many questions during report.

* An ancillary nutritional aide told the nurse manager she doesn’t want to interact with Sylvia after hearing her say on numerous occasions that the hospital’s food is “horrible” and she “wouldn’t feed it to a dog.”

1) Is there a difference between lateral violence, vertical violence, and horizontal violence? Explain.

2) Do you agree with the nurse manager’s handling of the situation? How have her actions hurt or helped the situation?

3) How would you further advise the nurse manager? How would you further advise the nursing peers?

B)
Horizontal & Lateral Viole
nce Case Study:

Use the corresponding article on Horizontal Violence to help answer the questions to the
following

two

case studies. Remember that all assignments need to be in APA format with a title
page and running header AND must include your OWN resea
rched professional reference that is
cited within your responses.

A new grad nurse.

Janet K. was a new graduate on the nursing unit. She was very excited to have
passed her NCLEX exams and was very pleasant and enthusiastic about starting work on her busy

unit.
The nurses on the unit knew that a particular physician, Dr. M. followed a specific routine for making
rounds. Janet K. had several of his patients that day but was unaware of his routine. The nurses on the
unit decided not to share that information

with her as they know that Dr. M would be arriving soon with
certain expectations of the nurse who would be making rounds with him. They decided that this would be
a “fun” way to “take her down a notch, and wipe that silly grin off her face.” Dr. M. arriv
ed and Janet had
not prepared his patients or his charts for his rounds. He began to berate her loudly in front of everyone at
the nurse’s station. The other nurses, retreated to the back in the medicine room and all smirked &
chuckled while Janet K. stood

red
–
faced and endured his tongue lashing. Janet K. learned to hide her
enthusiasm for nursing and stayed on the unit long enough to be oriented and to complete the required
six months before transferring to another unit in the hospital.

What examp
les of horizontal violence are seen in this case study? Describe them.

What are some of the effects that horizontal violence can have on a nursing unit or healthcare
institution?

Based on the article and the recommendations that it provides
, how would you advise nurse Janet
to handle each of the situations?

A confrontational attitude.

Sylvia Stevens has worked at the hospital for four years. In the last few
months, several of her coworkers have provided the nurse manager of their unit
with negative feedback
about her behavior. All have described confrontational and unprofessional interactions with Sylvia. Sylvia
is often seen rolling her eyes during the “shift huddle,” when the nurses gather to discuss each patient,
and has yelled at co
workers on the unit.

After each incident, the nurse manager asked Sylvia’s coworkers to speak to her about the offensive
behavior. In each case, when the coworker told Sylvia she didn’t appreciate her behavior, Sylvia denied it
had occurred and ended the c
onversation. The nurse manager has also spoken with Sylvia three times in
the past year about her behavior, and this has led to temporary improvements. A few months after these
discussions, however, the negative, abrasive, and aggressive behavior that Sylv
ia’s peers have described
resurfaced.

In the last four weeks, Sylvia’s colleagues have reported several negative interactions.

* A physician’s assistant complained that Sylvia made a comment about a patient’s “disgusting” body odor
within earshot of the pa
tient.

* A nurse coworker described how Sylvia yelled at her for asking too many questions during report.

B) Horizontal & Lateral Violence Case Study:
Use the corresponding article on Horizontal Violence to help answer the questions to the
following two case studies. Remember that all assignments need to be in APA format with a title
page and running header AND must include your OWN researched professional reference that is
cited within your responses.
A new grad nurse. Janet K. was a new graduate on the nursing unit. She was very excited to have
passed her NCLEX exams and was very pleasant and enthusiastic about starting work on her busy unit.
The nurses on the unit knew that a particular physician, Dr. M. followed a specific routine for making
rounds. Janet K. had several of his patients that day but was unaware of his routine. The nurses on the
unit decided not to share that information with her as they know that Dr. M would be arriving soon with
certain expectations of the nurse who would be making rounds with him. They decided that this would be
a “fun” way to “take her down a notch, and wipe that silly grin off her face.” Dr. M. arrived and Janet had
not prepared his patients or his charts for his rounds. He began to berate her loudly in front of everyone at
the nurse’s station. The other nurses, retreated to the back in the medicine room and all smirked &
chuckled while Janet K. stood red-faced and endured his tongue lashing. Janet K. learned to hide her
enthusiasm for nursing and stayed on the unit long enough to be oriented and to complete the required
six months before transferring to another unit in the hospital.
1) What examples of horizontal violence are seen in this case study? Describe them.
2) What are some of the effects that horizontal violence can have on a nursing unit or healthcare
institution?
3) Based on the article and the recommendations that it provides, how would you advise nurse Janet
to handle each of the situations?

A confrontational attitude. Sylvia Stevens has worked at the hospital for four years. In the last few
months, several of her coworkers have provided the nurse manager of their unit with negative feedback
about her behavior. All have described confrontational and unprofessional interactions with Sylvia. Sylvia
is often seen rolling her eyes during the “shift huddle,” when the nurses gather to discuss each patient,
and has yelled at coworkers on the unit.
After each incident, the nurse manager asked Sylvia’s coworkers to speak to her about the offensive
behavior. In each case, when the coworker told Sylvia she didn’t appreciate her behavior, Sylvia denied it
had occurred and ended the conversation. The nurse manager has also spoken with Sylvia three times in
the past year about her behavior, and this has led to temporary improvements. A few months after these
discussions, however, the negative, abrasive, and aggressive behavior that Sylvia’s peers have described
resurfaced.
In the last four weeks, Sylvia’s colleagues have reported several negative interactions.
* A physician’s assistant complained that Sylvia made a comment about a patient’s “disgusting” body odor
within earshot of the patient.
* A nurse coworker described how Sylvia yelled at her for asking too many questions during report.

Read the above article: The role of aggression suffered by healthcare workers as predictors

help you answer the following questions related to the topic of “Nurse Burnout”.

Explain what “Nurse Burnout” means and what are several causes?

Does violence in healthcare contribute to “Nurse

Burnout”?

What are some of the long term effects of “Nurse

Burnout”?
1.

What suggestions do you have to alleviate this problem?

(A)

Read the above article: The role of aggression suffered by healthcare workers as predictors

to
help you answer the following questions related to the topic of “Nurse Burnout”.

Explain what “Nurse Burnout” means and what are several causes?

Does violence in healthcare contribute to “Nurse Burnout”?

What are some of the long term effects of “Nurse
Burnout”?

What suggestions do you have to alleviate this problem?

(A) https://www.youtube.com/watch?v=1RAKl2Nl2mo

Read the above article: The role of aggression suffered by healthcare workers as predictors to

help you answer the following questions related to the topic of “Nurse Burnout”.

 Explain what “Nurse Burnout” means and what are several causes?

 Does violence in healthcare contribute to “Nurse Burnout”?

 What are some of the long term effects of “Nurse Burnout”?

 What suggestions do you have to alleviate this problem?

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