APNA Position: Violence Prevention

Approved by the APNA Board of Directors July 12, 2016. Revised November 2020, April 2022.

Introduction

The issue of violence in our society demands careful attention and preventative actions. Violence affects everyone, in all stages of life.; regardless of age, race, or economic status (CDC, 2016). Violence is a public health issue that creates physical, emotional, psychological, and spiritual challenges and problems for survivors. It can also have a negative effect on diverse communities by causing economic loss, social disruption, loss of productivity, and diminished quality of life. While the majority of violent events occur outside hospitals, workplace violence remains a significant issue in the health care environment and is of great concern to psychiatric-mental health (PMH) nurses and the diverse populations they serve.

Due to the multifaceted etiology and characteristics of violence, rather than relying on one classification of violence, the APNA Council for Safe Environments (CSE) recommends the following definitions of violence:

1. “Violence is the use of physical/verbal force or power, threatened or actual, against oneself, another person, or against a group or community, that either results in or has a high likelihood of resulting in injury, death, psychological harm, maldevelopment or deprivation” (WHO, 2020).
2. Aggression, an integral component of violence:

• • Physical aggression: Action intended to inflict pain, bodily harm, or death on another.
  • Verbal aggression: Verbally hostile statements that seek to inflict psychological harm on another through humiliation, devaluation/degradation, intimidation, social rejection or threats towards others.
  • Aggression against property: Destruction of property, objects, or possessions of others.
  • Autoaggression: Physical injury toward oneself, self-mutilation, or suicide attempt. (Allen et al., 2019)

3. Workplace violence, referring specifically to violence in the healthcare setting: “Workplace violence is any act or threat of physical violence, harassment, intimidation, or other threatening disruptive behavior that occurs at the work site. It ranges from threats and verbal abuse to physical assaults and even homicide. It can affect and involve employees, clients, customers and visitors” (OSHA, 2020).
4. Microaggression: A microaggression is a subtle behavior – verbal or non-verbal, conscious or unconscious – directed at a member of a diverse and marginalized group that has a derogatory, harmful effect. (https://www.thoughtco.com/microaggression-definition-examples, 2020)

The U.S. Department of Labor, Occupational Safety and Health Administration (OSHA) reported that violence in healthcare occupations represented more than 10% of all workplace violence incidents (OSHA, 2016). OSHA suggests that actual rates may be much higher due to widespread underreporting. Accurate data on workplace violence is also hindered by a lack of universally accepted definitions and standardized reporting measures (Allen et al., 2019). According to the Occupational Health Safety Network, nurses have the highest rate (40.2%) of workplace violence injuries recorded by participating hospitals (Groenewold et al., 2018), and physicians, particularly in emergency medicine, are also frequently victimized (The Joint Commission, 2018). Thus, violence and aggression toward staff in the health care setting is highly prevalent and problematic, particularly in emergency departments and in acute care settings where patients receive psychiatric and substance use treatment (Gillespie, Pekar, Byczkowski, & Fisher, 2017; Staggs, 2015).

Risk is inclusive to anyone present. Violence is not limited to acute health care settings but can occur in any bio-behavioral healthcare setting. Persons from diverse populations are at greater risk for violence than non-diverse populations (SAMHSA, 2020).

Violence Prevention

No matter what the circumstances, the issue of violence prevention is complex and requires an interprofessional approach. Violence prevention in the hospital and other healthcare settings relies on a set of interrelated processes involving risk identification, prevention strategies, that promotes positive engagements across all populations. These three processes are briefly outlined below. The World Health Organization (WHO, 2010; 2016a-c), the Centers for Disease Control (CDC, 2018), and the Substance Abuse and Mental Health Services Administration (SAMHSA, 2020) provide extensive online resources to guide violence prevention.

Identifying Risk and Protective Factors

There are multiple reasons why one person experiences and/or perpetrates acts of violence. The goal of violence prevention is to decrease risk factors and increase protective factors (CDC, 2018). To that end, hospital and other healthcare setting staff should become familiar with potential risk and protective factors associated with violence and solicit specific data cultural nuances when assessing individuals or communities. For instance, agitation (a notable risk factor) often precedes violence (Vieta et al., 2017a). People who present to hospital emergency departments (EDs) often become agitated for a variety of reasons. Recognizing early warning signs of agitation can preempt violence, particularly with a patient-centered response (Bowers, 2014a; Scheck, 2011; Vieta et al. 2017b; Zeller & Rhodes, 2010). Richmond and the Emergency Psychiatry Group BETA position statement (2012) supports this approach, recommending the replacement of restrictive methods of treating agitated patients with non-coercive interventions that include engagement, collaboration, and de-escalation. Along with de-escalation, there are multiple violence assessment tools, and these can be helpful in identifying patients and persons at risk (Gaynes et al., 2017). Two violence assessment tools to consider are the Broset Violence Checklist (BVC) (Abderhalden et al., 2006; Clarke, Brown & Griffith, 2010) and the Dynamic Appraisal of Situational Aggression (DASA) (Ogloff & Daffern, 2006): Both have demonstrated effectiveness at predicting violence on inpatient psychiatric units (Ghosh et al., 2019).

Developing and Testing Prevention Strategies

Patient-centered, trauma-informed, recovery-oriented practices are an integral element of violence prevention (Beattie et al, 2019; Bloom, 2017; Olsson & Schön, 2016). Connecting with people in distress via therapeutic relationship strategies (Hamrin, Iennaco & Olsen, 2009) and focusing on meeting each individual’s unmet needs (Hallett et al., 2014) may prevent unnecessary frustration and anger that often trigger violence. Because imposition of restrictions exacerbates the problem of violence, an approach that is sensibly cautious, yet not overly reactive or controlling, is most effective (Bowers et al., 2009).

Moreover, coercive measures based on control are in direct conflict with patient-centered, trauma-informed care. Nurses cannot control the behaviors of others, but can control their own responses to those behaviors (Allen, 2014). Len Bowers (2014) found that there is a correlation between using controlling interventions and violence; units which use controlling interventions often have more violence, resulting in increased risk to staff and patients. Thus, a critical violence prevention strategy is one that develops culturally relevant communication techniques that decrease controlling and coercive interactions and increase staff use of positivity, empathy, softer words, conflict resolution and reassurance (Bowers, 2014).

Finally, violence prevention via engagement depends on the broader organizational culture. The organizational culture sets the tone for the way patients are to be treated and the care values that manifest in staff actions. Leadership develops this culture (Beckett et al., 2013); thus leaders must implement and support collaborative, team-based, relationship-based, trauma-informed, and recovery-oriented models of care that may reduce violence (Barker, 2001; Bowers, 2014; Huckshorn 2006, 2007; Mahoney, 2012; SAMHSA, 2016; Snorrason & Biering, 2018) and are grounded in civility and cultural humility.

• Cognitive Rehearsal is recommended as an evidence-based intervention to address incivility and lateral violence (Griffin & Clark, 2014). Cognitive Rehearsal involves didactic instruction, identifying phrases, and rehearsing appropriate responses with continued practice. Griffin & Clark (2014) provide an outline of common uncivil behaviors by nurses with corresponding appropriate cognitive rehearsal responses (p. 540).
• Workplaces should assure wide-spread adoption of the CDC’s Preventing Multiple Forms of Violence: A Strategic Vision for Connecting the Dots (2016).
• Leadership should provide and implement strategies for the PMH nurse to address and manage microaggression and support initiatives which address cultural humility, diversity, equity, and inclusion.

Violence Prevention via Staff Engagement

A growing body of evidence supports the concept that nurses can prevent violence by actively engaging with individuals and identifying signs of distress related to possible violence (Polacek et al., 2015). Elaborating on that principle, Ray et. al. (2011 and 2017) described nursing protocols designed to partner with patients in management of violent impulses. Using these ideas, nurses can engage patients who have suicidal and self-injurious thoughts and help them to identify alternative coping skills. This relationship, based on engagement, can inspire hope and reduce the feelings of isolation, ultimately reducing self-injurious and suicidal impulses. Additionally, forming a relationship based on engagement is equally important with patients who are agitated, violent or disruptive. PMH nurses should implement care plans based on helping the patient control impulses, while also meeting the patient’s perceived needs. These interventions provided in a caring relationship form the basis of an alliance and help to facilitate early interventions with risky behaviors before they occur.

The Broader Implications of Nursing Actions

Nursing practice includes active participation in the development of policies and mechanisms that promote safety for both inpatient and diverse community environments (Altman, Butler, & Shern, 2016; American Nurses Association, 2011). PMH nurses also have a pivotal impact on workplace violence prevention owing to their knowledge of interpersonal relationships, conflict resolution, and violence prevention strategies. PMH nurses have the opportunity to educate individuals about cultural nuances, as it pertains to, violence, violence prevention, and risk and protective factors in a variety of diverse settings and contexts. PMH nurses are in an excellent position to work with individuals, systems, friends/acquaintances, and family members of different backgrounds on strategies to identify and resolve intolerable feelings in a non-violent manner using evidence-based best practices.

Nurse leaders can create and support nursing education and workplace policies that do not tolerate aggression or violence in any form (Dillon, 2012). A survey conducted by the Emergency Nurses Association (2011) found that higher commitment to violence mitigation from hospital administration, ED management, and the presence of reporting policies (especially zero-tolerance policies), were correlated with less physical violence and verbal abuse. The theme of engagement in violence prevention carries over from inpatient settings to community outpatient settings, where PMH nurses often encounter intimate partner violence, sexual violence, elder abuse, suicidality, bullying, digital harassment and homicidality.

Conclusion

Trusting relationships between PMH nurses and individuals, families, and members of the community are essential elements in the effort to prevent most types of violence. Through these relationships, PMH nurses are positioned to be at the forefront of violence prevention efforts by assessing risk factors, providing counseling and education, and acting as role models while actively working to identify and acknowledge cultural norms related to violence. PMH nurses have an ethical and best practice responsibility to facilitate and implement interventions and strategies to reduce and ultimately prevent violence (Healthy People, 2020). As leaders, caregivers, educators, and members of one of the most trusted professions in America, PMH nurses have the opportunity to teach and promote violence prevention approaches and strategies, as well as cultural humility approaches and strategies, when they interface with diverse individuals, families, and communities in an equitable manner.

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Approved by the APNA Board of Directors July 12, 2016.
Revised and approved November 10, 2020, October 2022.