"We've had nurses get kicked so hard they could hardly stand up, and they're asked to finish their shift."
Violence against nurses—from patients, their visitors, doctors, and even other nurses—is so common and often shrugged off by administrators and lawmakers that many nurses feel no choice but to accept violence as just another part of the job.
“I can’t tell you how many times I’ve been punched, kicked, spit at,” says Susan Letvak, a professor at the University of North Carolina at Greensboro School of Nursing.
Sometimes the violence is so horrific that it can't be denied—there are countless stories of nurses strangled with their stethoscopes, punched in the face, stabbed with knives and pens, kidnapped, and sexually assaulted.
But most acts of violence against nurses are massively underreported because of a culture that tolerates violence against women, pressures nurses to accept behavior that no other profession would tolerate, and staffing shortages that both make violence more likely and nurses feel more guilty about taking the time to report.
“The data are very imperfect,” explains Judy Arnetz, a professor in the department of family medicine at Michigan State University. “What we have on a national level is the Bureau of Labor Statistics with some additional data from the Justice Department. This is all serious violence. What we’re not getting a good measure of is low level violence, or violence that doesn’t result in a serious physical injury.”
According to the American Nurses Association Health Risk Appraisal, nearly a quarter of nurses do not feel comfortable reporting violence. That’s mostly in line with a survey of Minnesota nurses that found more than thirty percent of physical assaults are not reported.
And while there may be a temptation to believe that no data means no problem, as Arnetz and colleagues have shown, violence is certainly the water in which nurses swim. One study of more than 5,000 nurses found that three-quarters experienced violence in the previous year—more than half had been verbally abused and nearly a third physically assaulted. Half of Texas nurses say they have been physically assaulted at some point in their careers.
One major reason that nurses don’t report these incidents is because they don't feel reporting will make a difference. “The administration doesn’t do much of anything about it,” says Sheila Wilson, a nurse and cofounder of the organization Stop Healthcare Violence. “It gets to the point where you don’t bother writing out incident reports.”
Another reason for the underreporting may be that the violence is unintentional—say, with older nursing home patients who are confused or are unable to communicate that a procedure is hurting or scaring them. Trish Powers, a staff nurse at the Brigham and Women’s Hospital and chairperson for the hospital’s unit of the Massachusetts Nurses Association, says two weeks ago a 350-pound patient became combative with her as he woke up from anesthesia. “He got a hold of my arm. It took three people to get him off of me,” says Powers. “It’s not like I reported that or anything. It’s an accepted norm.”
Yet, other times, it may be that nurses consider assault to be the occupational hazard of directly caring for people at the worst and most dangerous moments of their lives. Take Mercy Emergency Department in Springfield, Missouri, for example, where five to eight of their sixty beds are patients with “psychosis, manic behavior, aggressive behavior, and altered mental status.” No wonder many emergency room nurses say that violence is “simply part of their practice.”
While proposed solutions tend to put the responsibility on the shoulders of already overworked nurses—for example, learning de-escalation or evasion techniques, they all rest on a shaky assumption of adequate staffing.
“A person who is confused probably needs more than one caregiver,” says Gordon Lee Gillespie, associate professor at the University of Cincinnati College of Nursing. “We need to get another person to be the eyes on the arms, eyes on the teeth, when I’m focused on an intervention or an assessment. But most states do not have minimum staffing guidelines.”
Since most hospitals seem more willing to safeguard their bottomline than nurses, advocates have turned to legislators to pass safe patient ratio laws. California is the only state with a safe patient ratio law. Researchers found that the law lowered nurse injuries by nearly a third. Right now, states, such as New York and Ohio, are pursuing their own safe patient ratio laws, while nationally two bills are currently in the House and Senate.
Without adequate staffing, nurses are less likely to report violence, especially when they are already operating with the fewest nurses possible. “We’ve had nurses get kicked so hard they could hardly stand up," Wilson says, "and they are asked to stay on to finish off their shift."
What makes the problem of violence against nurses even worse is that the violence doesn’t only come from the outside. More than half of new nurses report having been put down by a senior nurse, and nearly half say they have been humiliated; called lateral violence, some experts estimate that such treatment can be so painful that nurses often leave their jobs within six months. “There is a saying, 'Nurses eat their young,'” says Carolyn Smith, assistant professor at the University of Cincinnati College of Nursing.
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Doctors are also notorious for disrespecting nurses; one survey found that forty percent of nurses felt bullied by physicians. Another study of obstetrics collected a series of dark but completely routine anecdotes about doctors who created an “an environment of fear,” intensity, and intimidation whenever nurses question orders, miss documentation, or "how dare they" report a doctor’s mistake, such as leaving a sponge in a patient.
To ask why violence against nurses is tolerated as an accepted norm in hospitals is to ask why violence against women is tolerated as an accepted norm in the United States. “Part of it stems from the fact that nursing is predominantly a female profession,” Gillespie says. “In America, we devalue women and their work and, as a result, it’s okay to strike a woman but it’s not okay to strike a man.”
“I’ve been called a bitch," Powers says, "more times than I could ever count."
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