Two recent violent episodes against nurses in emergency departments have again highlighted the issue of inadequate protections for nursing staff.
In both cases the nurses, from Wyong Hospital on the central coast of NSW and The Royal Melbourne Hospital in Victoria, were held hostage by knife-wielding patients. These cases seem extreme, but they are not isolated.
Nurses are exposed to high levels of physical and verbal violence, to the point where this has become an expected and even accepted part of their job.
In 1999, the Australian Institute of Criminology ranked the health industry as the most violent workplace in the country. According to US statistics, health-care workers are five to 12 times more likely than other workers to experience violence in the workplace.
Worldwide, nurses are more likely to be attacked at work than prison guards and police officers. And yet such incidents remain under-reported and existing protections are not enough to ensure the safety of nurses and their patients.
Extent of violence
Nurses are at the front line of violence in hospitals, particularly those working in emergency, aged care and mental health. The frequency and severity of violent incidents are increasing, yet such episodes remain vastly under-reported.
Government figures show the number of “code blacks” – incidents where the safety of hospital staff is threatened – is rising. By February this year, 6,245 code blacks had been reported so far for 2016-17, compared to 4,765 at the same point in 2015-16, in South Australian public hospitals.
Emergency departments have the highest incidence of violence in health care. Up to 90% of emergency department staff have experienced some type of violence in their careers. Violence covers a range of behaviours, from verbal abuse and threats through to physical violence.
Verbal abuse, especially swearing, is the most common type of violence. Nurses in emergency departments experience daily verbal abuse. Physical violence often occurs at the same time as verbal abuse and can include the use of weapons on hand – such as syringes, scalpels, scissors and furniture.
Patients are responsible for most of the violence committed against nurses. This includes children and their parents or carers. Patients under the influence of alcohol or drugs, including ice, and those with mental health issues are the most likely to become violent.
Impact of violence
The impact of patient-related violence on nurses is far-reaching. Verbal abuse can cause significant psychological trauma and stress to nurses, even if no physical injury has occurred. This can include symptoms of depression, post-traumatic stress disorder, drug and alcohol abuse and even chronic pain – all of these can last up to 12 months after an incident.
The types of physical injuries nurses sustain range from minor scratches and bruises, through to serious injuries such as fractures, stab wounds, attempted strangulations and even death.
In 2011 a nurse was punched in the face and stabbed with a butter knife in the arm, back and breast area. In 2011 a patient stabbed a mental health nurse to death in regional NSW. And in 2016, a remote area nurse was abducted, raped and murdered in northern South Australia.
Exposure to patient-related violence can also affect the way nurses interact with patients. They can feel less empathy and their quality of care can suffer. There’s a link between violence experienced by nurses and subsequent adverse events in patients. These included late administration of medications and an increase in the number of patient falls and medication errors.
Some strategies can prevent and manage violence. These include using security guards, duress alarms, workplace design and training in aggression minimisation for front-line staff.
The Australasian College for Emergency Medicine recommends a lack of hiding spaces outside emergency departments, the use of CCTV cameras, a visible security presence, physical barriers such as glass screens at triage (the area where the nurse assesses the severity of your condition in relation to other emergency department patients), a restricted access area and good lighting.
The use of such strategies is inconsistent in Australia. Training in aggression minimisation is designed to improve the knowledge and skills of staff in recognising and responding to potentially violent people. It is compulsory for those working in high-risk clinical areas like the emergency department. Yet large numbers of nurses have not completed any training or have not completed the regular refresher programs required.
Security guards are not present in all Australian emergency departments, and are often ill equipped to deal with the levels of violence they encounter. They are unarmed and do not carry handcuffs. As they are meant to observe and report on episodes, they lack powers to restrain or detain people who threaten or assault hospital staff.
In 2016 a patient under the influence of ice shot a security guard and police officer at Sydney’s Nepean Hospital. In some smaller hospitals no security is provided after hours. This is despite the fact regional nurses experience the same levels and types of violence as their metropolitan colleagues.
Little has changed
In response to increasing violence in NSW public hospitals, in February 2016 the then NSW health minister, Jillian Skinner, issued a 12-point action plan for increasing security. A detailed security audit was conducted in 20 emergency departments.
Wyong Hospital was one of those audited. But the recent violent attack on two nurses seems to indicate not much has changed.
Given the strategies in place are inadequate and staff continue to be attacked on the job, changes must be introduced as a priority. The management of violence needs to catch up with the daily reality facing health-care staff, to ensure workplace and personal safety are valued alongside patient safety.