World Report www.thelancet.com Vol 383 April 19, 2014 1373 Published Online April 16, 2014 http://dx.doi.org/10.1016/ S0140-6736(14)60658-9 For the study by Spector and colleagues see http://www. journalofnursingstudies.com/ article/S0020-7489(13)00035- 7/fulltext For the WHO study see http:// www.who.int/violence_injury_ prevention/violence/activities/ workplace/WVsynthesisreport. pdf For more on the Hong Kong initiative see http://www.wma. net/en/20activities/40healthsyst ems/60violence/Proceedings_ Violence_Health_Sector_2010. pdf Tackling violence against health-care workers Globally, health-care workers experience high rates of violence and abuse in the workplace. More focus should be put on preventing such attacks, say experts. Roxanne Nelson reports. It was a night shift like any other, in the emergency room at a large, urban academic medical centre in the USA. Stanley Johnson, a nurse who had been employed by the facility for nearly two decades, accompanied an intoxicated 20-year-old man to the phone so he could call his mother to pick him up. The man took the phone, and then punched Johnson in the face. But all things considered, apparently Johnson was lucky. In the emer gency depart ment waiting area for another hospital, the Bronx-Lebanon Hospital Center in New York, a man entered carrying a concealed weapon. Once in the waiting room, he pulled it out and fi red into the crowd, wounding a nurse and a security guard. In the state of Texas, the 22-year-old son of a patient went on a knife-slashing rampage in the Ambulatory Surgical Center of Good Shepherd Medical Center. He stabbed one of the nurses in the chest and killed her, and wounded four others. What is most disturbing about these incidents is that they are not unique or isolated events. Physical violence against nurses and other medical workers has become an endemic problem in health care. In addition, nonphysical assaults, such as bullying and sexual harassment, are also common. Although some countries are beginning to address the problem, much remains to be done to encourage reporting of incidents and to prevent them from happening in the fi rst place. Global problem The USA has a less than stellar reputation for violence, and the workplace is a common site of violence, with health-care settings particularly prone to it. The rate of assaults on health workers is higher than that of other occupations—eight assaults per 10 000 workers compared with two per 10 000 for the general workplace. There were 91 shooting incidents inside US hospitals between 2000 and 2011. But even though they receive a great deal of publicity, shootings are relatively rare events. And despite having a culture of violence, the USA is not alone in dealing with this situation. Violence against health personnel is a widespread problem throughout the industrialised world, as well as in developing and transitional countries, and affects health-care workers in nearly all work environments. Although guns can make an attack more lethal, assault can take the form of intimidation, harassment, stalking, beatings, stabbing, and rape. Perpetrators tend to be primarily patients, their families, and visitors. In a large review published in 2013, Paul Spector, a professor of psychology at the University of South Florida, FL, USA, and colleagues analysed data for more than 150 000 nurses, drawn from 160 global samples. They found that overall, about a third of nurses have been physically assaulted, bullied, or injured, while around two-thirds have experienced nonphysical assault. Even though assault can and does occur in all settings, most violence occurs in a small number of areas, says Spector. “The emergency department and geriatric and psychiatric units have high rates”, he says. “Many other settings have relatively little violence. Nurses in high-risk settings are working with people who are in pain, under stress, and often feel they have lost control of their lives. Geriatric and psychiatric patients often have poor impulse control.” The diff erent types of violence also varied by region. The highest rates of both physical violence and sexual harassment were in the “Anglo” region, which included Australia, England, Ireland, USA, Canada, New Zealand, and Scotland. Bullying was lowest in Europe, but highest in the Middle East, and the rate of sexual harassment was lowest in Europe. An earlier country case study undertaken by WHO and several partner agencies, reported that more than half of responding health-care personnel experienced at least one incident of physical or psychological violence in the previous year: 76% in Bulgaria; 67% in Australia; 61% in South Africa; 60% in health centres and 37% in hospitals in Portugal; 54% in Thailand; and 47% in Brazil. Greatly underreported The actual rate of assaults is probably much higher than in the published literature, due to underreporting. “It is believed that 70 to 80% of assaults Accident and emergency departments are high-risk environments for violence “‘...Nurses in high-risk settings are working with people who are in pain, under stress, and often feel they have lost control of their lives...’” Gu st oi m ag es /S cie nc e Ph ot o Li br ar y 1374 www.thelancet.com Vol 383 April 19, 2014 World Report are never reported”, says Lesley Bell, a consultant with the International Council of Nurses in Geneva. “Often nothing is done to help the person who has been attacked, and hospitals may even discourage workers from reporting it.” As a group, nurses are often the most likely to experience an assault in the workplace, and many believe that being assaulted may just be part of the job, explains Bell. In addition, many also believe that taking legal action against an attacker can cost them their jobs. “It goes back to how we are valued as a profession”, says Bell. “And we are seeing the societal tolerance for violence spilling over. Physical assault is one of the things that historically has been accepted as part of the job for nurses. In home health, for example, nurses are often expected to go into areas where police won’t even go.” A 2011 survey by the Emergency Nurses Association in the USA found that most nurses did not fi le a formal report when assaulted, but did notify someone. The survey also found that in nearly half of all cases of physical violence, no action was taken against the perpetrator. Nurses also received no response from the hospital about the assault in about 70% of cases. Reversing the trend In the USA, 30 states have now passed laws making it a felony to assault hospital workers and some individual facilities have begun to take workplace violence more seriously. The American College of Emergency Room Physicians has recommended interventions such as increasing the number of security officers, closed circuit television cameras with 24-hour trained observers, panic buttons, and better control of the entry into the emergency department. The Henry Ford Hospital in Detroit implemented metal detectors in an eff ort to prevent weapons from entering the facility. In their fi rst 6 months of screening, officials confiscated 33 handguns, 1324 knives, and 97 chemical sprays. “In Europe and in the UK, we do have anti-bullying laws”, says Cary Cooper, distinguished professor of Organisational Psychology and Health at Lancaster University, UK. “And it can be physical or psychological. If it’s psychological, it has to be persistent, but if it’s physical, one act is enough.” In emergency areas, where a large percentage of incidents occurs, Cooper points out that the wait is often long, people are sick, injured, anxious, worried, intoxicated, and it is easy to see how the aggression builds up. “In other areas, a patient may also have to wait a long time for care”, he says. “And if the nurse doesn’t explain why the wait is long, or maybe why the care isn’t given fast enough, that can also lead to a buildup in aggression.” There are many reasons why people become violent, but the key is how to deal with it, Cooper says. Facilities have to be fi rm in not tolerating that behaviour, regardless of the reason. “You do see signs in hospitals saying that abuse will not be tolerated, and making it clear that it is not acceptable”, he said. “And in the UK people are arrested for assaulting health-care workers.” But preventing attacks pre- emptively would be the best strategy. “Violence can be reduced by skilful interpersonal treatment of patients, such as providing information and showing concern”, says Spector. “Many of the same factors that aff ect the patient also affect family and friends. Like the patient, they can be under emotional distress and feel loss of control. They also can react to the treatment of the patient. Practices to help sooth patients can also be used by family or friends.” In Hong Kong, where workplace violence is common in acute psychiatric wards, a working group was formed in one acute admission unit of Castle Peak Hospital, and an integrative programme was developed. The goal was to prevent both patient and staff injury due to violence, as well as developing a harmonious working atmosphere, and building up trust and respect between patient and staff . Part of the plan was also to develop competence among staff in managing workplace violence, and one of the interventions was to hold “drills”, so that workers would have an opportunity to practice their learned skills and techniques in a clinical environment. In turn, these practice session would empower them to respond appropriately in actual situations. But for the emergency depart ments, where workers face the highest risks, Cooper advocates taking prevention a step further. “The fi rst port of call is the most important one, which would be the receptionist or the person who does intake”, he says. “Those persons can be trained to recognise a problem and try to diff use it before it escalates into violence. This will help reduce the risk of danger.” Roxanne Nelson “‘Violence can be reduced by skilful interpersonal treatment of patients, such as providing information and showing concern’...” Around 70–80% of assaults on health-care workers are never reported Jim V ar ne y/ Sc ie nc e Ph ot o Li br ar y