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Opinion Piece
Keeping Nurses Safe
An industry perspective
Fiona Armstrong
(on behalf of the Australian Nursing Federation)
Article Text
The decision by Contemporary Nurse to devote an entire issue to the subject of violence against nurses is a sober acknowledgment of the significance of violence as an occupational hazard for nurses. The serious nature of many attacks, and the potentially catastrophic effects of violence on victims, their families, and ultimately on the nursing profession is of grave concern to all nurses. Finding solutions to such an intransigent problem requires serious public debate and it is therefore appropriate that such a discussion be conducted with an informed discourse from the profession so often targeted. As the English philosopher Francis Bacon famously observed: 'Knowledge is power'. It is to be hoped that through the dissemination of knowledge that the power to arrest the insidious march of violence in nursing is generated.
The prevalence of violence against nurses however rests uneasily with another widely acknowledged truism of nursing: that nurses are highly regarded by the community, being consistently rated as the most honest and ethical occupational group (The Morgan Poll 2005). As a discipline where caring is a central value, nursing offers the opportunity to indulge intellectual curiosity, conduct rational inquiry, exercise problem-solving skills, and develop creativity, while retaining compassion, advocacy and holism as core attributes (Lyneham 2001). Few people will pass through life without experiencing at some point the benefits of nursing care. Nurses, more than any other health professional, care for the health of individuals and communities across the globe, and their safety should therefore be a community priority.
Australian nurses at risk
A 1999 report by the Australian Institute of Criminology identified the health industry as the most violent industry in Australia. Nurses recorded the second highest number of violence related workers' compensation claims, ranking second only to security guards, and higher than police and prison officers (Lyneham 2001).
A University of Tasmania study in 2003 found 64% of respondents had experienced violence at work, and one in ten nurses had left a job because of abuse (Farrell and Bobrowki 2003). A more recent study in Queensland suggests 90% of nurses experience verbal abuse and 75% physical abuse (Kelly 2005). Nurses are most at risk in emergency, mental health, or rural settings where they may work alone, and (increasingly) in aged care settings (Mayhew and Chappell 2003).
Nurses' working conditions make them vulnerable
Inadequate staffing levels and skills mix, which lead to excessive workloads for nurses, all leave nurses vulnerable to violence as they struggle to meet the needs of clients in health care facilities. Funding cuts, which generate increased waiting times for care, also increase the frustration and aggression of patients and their relatives toward nurses (Genovese 2003).
The increasing incidence of mental illness in the community, mainstreaming of mentally ill patients into the acute hospital sector, increasing levels of drug and alcohol abuse in communities, and an ageing population (increasing the number of individuals with dementia in aged care and acute facilities) have all been identified as contributing to increased levels of violence against nurses. Research indicates the most common perpetrators of violence against nurses are patients/clients (Hegney, Plank & Parker 2003). They are disproportionately male, affected by drugs and/or alcohol, and commonly have a history of violent or aggressive behaviour (Mayhew and Chappell 2003). The inappropriate design of health facilities, which fail to take into account potential threats and the need to ensure the safety of staff and clients within them, also contribute to risk.
Recruitment and retention
Workplaces with high levels of violence unsurprisingly also experience low morale, and make the already challenging task of recruiting and retaining nurses even more difficult. With data suggesting 48% of nurses are at risk of leaving the profession, the importance of mitigating this 'push' factor becomes critical (Best Practice Australia 2003). Ensuring a safe working environment is paramount to keeping nurses in, and attracting new members to, the profession.
What types of violence do nurses experience?
The types of violent incidents nurses experience range from verbal abuse and threats to physical assaults (punching, kicking) to stabbing, shooting and attempted strangulation. The Queensland Nurses Union (ANF, QLD) reports: 'Nurses have been held at gun point, they have been stabbed, they have been physically punched until their bones are broken, the psychological impact of which can never be measured.' (Queensland Nurses Union 2004). In a six week period in July 2005, the New South Wales Nurses Association (ANF, NSW) reported five assaults, including attempted strangulations of their members.
Occupational health and safety legislation
As a principle articulated in occupational health and safety legislation in every Australian state and territory, the provision of a work environment that is safe and without risks to health (ie free from occupational violence and aggression) is the legal right of all employees. But this legal right is not achieved simply by the beneficence of governments - rather it is the advocacy of representative groups (ie unions, such as the Australian Nursing Federation) that compels governments to act. Indeed, unions have been at the forefront of improvements in occupational health and safety in Australia and around the world, and members of such organisations rightly expect that ensuring their health and safety is an integral part of union activities on their behalf.
The benefits of unions
Research published in the UK last year revealed workplaces with high levels of union membership reported higher levels of compliance (around 80%) with health and safety legislation (Ontario Workplace Health and Safety Agency 1994, 1996). Australian research indicates unionised workplaces in Australia are three times more likely to have a safety committee, and twice as likely to have undergone a management safety audit in the previous year as non-unionised workplaces (Trade Union Congress 2004).
The contribution of the ANF to nurses' safety
The Australian Nursing Federation (through its branches in every state and territory) has demonstrated significant leadership in developing guidelines and constructing policies to help protect nurses from violence at work. The ANF also contributes significantly to the safety of nurses in Australia by ensuring that industrial frameworks, such as enterprise bargaining agreements (collective employment agreements between nurses and their employers) contain provisions to ensure that employers and employees cooperate to 'control and manage health and safety hazards' such as violence and aggression and reduce workplace injuries through the implementation of risk management systems such as: hazard identification, risk assessment and control, and safe work practices. While these provisions cannot and do not remove the risks of violence occurring, they do ensure there is a clear understanding that there is a shared responsibility to address the risks, and that a failure to do so is a contravention of the legally enforceable agreement.
The Queensland Nurses Union (ANF, QLD) launched its 'zero tolerance' policy in 2000, an internationally endorsed approach to prevention, which expressly states that violence against nurses is unacceptable, and that nurses do not have to tolerate it. It articulates the responsibility of employers in developing and implementing strategies to prevent and manage occupational violence and aggression, and of governments in ensuring that legislative and policy frameworks exist to protect nurses.
In 2001, following requests by the NSWNA (ANF, NSW), the NSW health department established a taskforce into violence in health care. The taskforce developed a zero tolerance policy and guidelines, updated its security and safety manual, developed an aggression management training package, and developed security design guidelines.
The Victorian branch of the ANF also adopted a 'zero tolerance to violence' policy in 2001. This includes a comprehensive definition of occupational violence and aggression, and outlines the principles of zero tolerance: of managing risk, the importance of staff training, appropriate building/facility design, the importance of reporting, and a collaborative approach.
Conclusion
While violence was once considered 'part of the job' for nurses, campaigns to raise awareness in the health and aged care sectors and the community about the incidence of violence and its unacceptability as a workplace hazard are beginning to empower nurses to report violent incidents, to act to minimise risk, and to ensure their employers accept their legal obligations to provide a safe place for nurses to work and to provide care for the community.
References
Best Practice Australia Pty Ltd (2003) Benchmarking Study into Nursing Attraction and Retention.
Farrell G and Bobrowki C (2003) Scoping workplace aggression in nursing (SWAN). Media briefing, Tasmanian School of Nursing, University of Tasmania.
Genovese M (2003) Hospital workplace is too violent, say nurses. New York State Nurses Association, 24 November. Available at http://www.nysna.org/news/press/pr2003/112403.htm
Hegney D, Plank A and Parker V (2003) Workplace violence in nursing in Queensland Australia: A self-reported study, International Journal of Nursing Practice 9: 261-268.
Kelly H (2005) Nurse morale plummets. Media release regarding research by Dr Gary Day, Queensland University of Technology, 9 June.
Lyneham J (2001) Violence in New South Wales emergency departments, Australian Journal of Advanced Nursing 18:2: 8-17.
Mayhew C and Chappell D (2003) The occupational violence experiences of 400 Australian health workers: An exploratory study. The Journal of Occupational Health and Safety 19:6.
Ontario Workplace Health and Safety Agency (1994, 1996).
Queensland Nurses Union (2004) Nurses: Worth looking after. Briefing document for the Queensland Minister for Health, the Hon. Mr Gordon Nuttall, February.
The Morgan Poll (2005) Community rating of most honest and ethical occupational group Available at www.roymorgan.com/news/polls/
Trade Union Congress (2004) The Union Effect Briefing paper, August. Available at http://www.tuc.org.uk/h_and_s/tuc-8382-f0.cfm#_edn11
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