Prevent Workplace Violence in Psychiatric Settings

Safety & Health Assessment & Research for Prevention (SHARP) — Research for Safe Work

The health care sector continues to lead all other industry sectors in incidence of nonfatal workplace assaults with 48% of all nonfatal injuries from violent acts against workers occurring in this sector. According to the National Crime Victimization Survey, mental health workers experienced the highest rate of simple assaults in the health care sector, with 43.2 assaults per 1,000 workers. According to research studies, psychiatric nurses report among the highest violent victimization rates among all types of nurses.

Workplace violence is defined as violent acts, including physical assaults and threats of assault, directed toward persons in a workplace or on duty. Washington House Bill 2899, passed in 2000 to address violence in health care, requires mental hospitals to give employees violence prevention training at least annually and to have procedures for reporting and responding to physical and verbal assaults. SHARP research efforts strive to determine more about the risk factors for workplace violence including assessing various situational and environmental factors which contribute to workplace violence in psychiatric health care settings with worker-client interaction. To address this issue, SHARP conducted individual interviews and focus groups in three psychiatric settings with the following objectives:

  • Obtain background information on managers' and staff perceptions of workplace violence hazards, solutions, and recent changes;
  • Understand the organization of work, workplace culture, physical and psychological demands and workplace violence exposure of the direct care staff in the current work scheduling conditions;
  • Review current workplace violence policies, reporting procedures, scheduling procedures, and assault prevention training.

We present here 2 key themes from our study findings, illustrated by quotes from interview participants, and recommendations for each theme.

Schedule control

Schedule control includes concerns regarding low staffing levels, long hours due to mandated and voluntary overtime, inconsistent teams from floating or pulling staff, and unscheduled absences. Many of the control issues are linked in a positive feedback loop. For example, low staffing levels lead to mandated and voluntary overtime. Working long hours through mandated or voluntary overtime results in stress, exhaustion, illness, and work-family conflict which lead to unscheduled absences. In turn, a high rate of unscheduled absences leads to increased mandated and voluntary overtime. Workplace violence and incivility are an additional stressor that contributes to this spiraling cycle of events.

The following causal loop diagram illustrates the study findings on schedule control in a systems feedback loop where plus (+) signs indicate increasing levels. In this diagram, constraints on when vacation time can be scheduled with pulling staff to other wards, mandated overtime, incidents of workplace violence and incivility, and unscheduled sickness absence contribute to conditions in the system that are positively reinforcing, resulting in work stress and exhaustion.

Schedule causal loop.

For example, floating or pulling staff from some wards to other understaffed wards at the start of a shift is a regular practice in some psychiatric settings to address inadequate staffing coverage. The challenges of this form of low schedule control for direct care staff are many including disrupted teams, poor quality and lack of continuity in patient care, staff frustration and disengagement, increased burden on regular staff, and increased risk for patient frustration and escalation that may lead to violent incidents as noted below by a supervisor:

"When you have to move staff around a lot, it just creates dangerous situations."
- Supervisory nursing staff

In addition, long hours, psychologically demanding work, inflexible schedules, and low schedule control contribute to employee excessive use of unscheduled absences to recover from stressful work conditions and illness, and to manage their work and nonwork lives.

"This is a 24/7 service. So that requires probably the majority of the nursing staff to work antisocial hours. They're working either evening shift or night shift. And they don't have regularly scheduled weekends off. So the question is, does that contribute to excessive unscheduled absences?"
- Supervisory nurse

Increased schedule control can contribute to direct care staff well-being and will likely reduce workplace violence.

Recommendations for schedule control:

  • Limit use of mandated and voluntary overtime.
  • Reduce pulling staff to other wards and maintain stable work teams on each ward.
  • Create a float pool of permanent workers who have the ability and desire to function in this capacity.
  • Identify options to increase schedule flexibility for direct care nursing staff.
  • Create a system and culture of schedule control.

Supervisor / Coworker Support and Incivility

Social support from the immediate supervisor and coworker-teams is a component of organizational culture. Social support in organizations is defined as employee perceptions that their supervisor and coworkers value their contribution and care about their well-being. Incivility can occur in workplaces with low social support from supervisors and coworkers.

Supervisor support and leadership are extremely relevant for patient and staff safety. In the psychiatric hospital setting, unit supervisors are influential on the wards through their occasional presence. The charge nurse is also influential in the role of immediate supervisor to floor staff.

"I talk to people about, 'Hey, you did a good job with that patient. Thank you for talking to him that way.' That changes people's minds. You have to make that one-to-one connection with somebody."
- Supervisory nurse

Direct care nursing staff must be equipped with the competencies and skills needed to effectively and efficiently organize and design patient care delivery practices. One skill of great importance to workplace violence prevention while delivering quality care is working together as a team. Teamwork was a theme of importance to direct care staff workers in particular, because their safety depended on coworker support and teamwork to safely manage agitated patients on the ward. At all levels of interviews teamwork was valued and reported on as, in some cases, successful and in others, tenuous or less successful.

"When an RN2 or 3 engages their people in decisions in which they have a stake, they feel included and they feel safer. Every time you put somebody in restraints or take them out, you have an opportunity to build team, or you have an opportunity to really strongly undermine the sense of, 'We're in this together.'"
- Safety Committee Focus Group

Incivility is low-intensity counterproductive behavior with ambiguous intent to harm the target and is in violation of workplace norms for mutual respect. Examples of incivility include hostility, inappropriate or loud tone of voice, nonverbal gestures such as glaring, failing to pass on information, exclusionary behavior, intimidation, put downs, and gossiping. Bullying is a more intense form of negative behavior and occurs when a target is exposed to negative acts, from unconscious incivilities to blatant emotional abuse and physical assaults; negative acts are repeated and there is a prolonged experience over time, 6 months or longer. The Joint Commission (TJC) published a Sentinel Event Alert on intimidating and disruptive behaviors in health care organizations that undermine a culture of safety - this document includes requirements for a new leadership standard (LD.03.01.01) effective January 1, 2009 and suggested actions for organizations.

"When you have staff who is bullying other staff, the whole team breaks down. And when the team doesn't work together, the patients pick up on it, and then you really have a problem. It's very unsafe."
- Supervisory Nurse Focus Group

Recommendations for supervisor and coworker support and incivility:

  • Train upper level management, unit directors, and supervisory nurses on the role of support in psychiatric settings, supervisor and coworker-team support behaviors, and how to foster these in the organization to create a culture of nonviolence and support for safety.
  • Develop and implement a "Respect in the Workplace" hospital incivility policy that defines and addresses incivility including the organizational response to uncivil/bullying behavior. Refer to TJC Standard LD.03.01.01 for guidance.

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