Strictly Clinical

Translational perspectives on violence

The United States Department of Labor, Occupational Safety and Health Administration reports that nearly 2 million American workers report being victims of workplace violence each year and that healthcare professionals are at higher risk.

Most healthcare providers have experienced threats or actual violence in their work place. Over the last decade, healthcare workers have accounted for approximately two-thirds of the nonfatal workplace violence injuries involving days away from work. Though many publications are available on this topic, the problem continues to escalate. Therefore, it’s critical to continue the dialogue to advance our understanding of violence and to translate research into practice to address this growing threat.

Hurting people hurt others

A recurrent theme in my research during private interviews with perpetrators of homicide and other violent crimes is that people who have been hurt tend to hurt others. Violent criminals are frequently adult victims of serious childhood abuse and neglect. Violent behavior can result from a combination of learned behaviors, epigenetics of environmental influence on gene expression, neurodevelopment, and neuroendocrine stress responses that are shaped by violence, neglect, or other trauma experienced during childhood. The severity of abuse victimization as a child is significantly related to neuroendocrine changes that are also significantly related to violent behavior of adults.

In my research, 93% of females who committed violent crimes had been victims of childhood abuse. Many of these adult victims of childhood abuse reported that they reacted violently toward people who remotely reminded them of someone who was abusive toward them or neglected their basic needs when they were a child. Or they saw their victim as a softer target, less threatening than their abuser, upon whom they could take out their anger and revenge. Even when there was no evidence of self-defense, but rather the crime was offensive, these perpetrators described situations precipitating their violent crime that were reminders of times when they had been victims in the past. It was as if they lashed out with all the built up anger from the past to avoid allowing anyone to hurt them again.

Considering this, when someone becomes angry, remember that their anger could result from other underlying emotions based on the person’s previous experiences more than the present situation. For example, nurses can be perceived as authority figures similar to an adult who abused or neglected someone in their childhood. Therefore, when a nurse is too busy to give someone the time they think they need or if a nurse is perceived to be overly authoritarian, causing harm, not respecting them, or neglecting something that is believed to be important in someone’s care, this could trigger responses resulting from years of abuse, disrespect, or neglect by others.

Substance abuse

Research has demonstrated that drugs and alcohol are known to trigger violent behavior. Individuals abusing alcohol and other substances are prevalent in health care settings due to the availability of substances of abuse, the conditions that bring them to seek medical care, perceived needs to self-medicate before visiting a loved one in distress, or people under the influence at the time of a traumatic event who accompany an injured victim to a healthcare setting. It’s extremely difficult to rationalize with someone under the influence of drugs or alcohol.


More than 80% of the prison inmates I interviewed admitted to being under the influence of substances at the time of their crime and most said the crime would never have occurred if they had not used the substance. Some inmates were extremely distraught and seriously regretted what they had done while under the influence of substances, and others who were not remorseful blamed the victim. Most substance abusers seemed to be self-medicating with drugs or alcohol as a means to address the pain of their past emotional trauma such as childhood abuse and neglect.

Prevention

There is no one prescribed way to avoid all forms of violence because each situation is different. However, the following guidelines may be helpful:

The potentially violent event

  • Stop, think, and read the situation carefully. Separate yourself from potential violence as quickly as possible.
  • Avoid a knee-jerk reaction and do the opposite to de-escalate rather than escalate violent behaviors. Remember that the person may be feeling uncared for and neglected. Speak slower, softer, and project a kind and caring attitude, keeping in mind that people who have been hurt often hurt others. Those who need love the most tend to do things to deserve it the least.
  • Displaying genuine concern for the person can de-escalate a potentially volatile situation. Appearing fearful may convey to the person that they should be feared, while a smile with kind words may convey to the person that they matter to you and that you do not plan to dismiss their concerns.
  • Look for ways to build up rather than tear down an angry person. I was able to de-escalate an angry and potentially violent trauma victim just by telling him how much better he looked and how much progress he had made since I saw him last while rejoicing with him about that. People need encouragement during times of anger and frustration about their loss of control or loss of function due to their current health condition. Patients’ loved ones need similar encouragement.
  • Permit the person to have as much control as possible over their choices for their care. Avoid appearing to be domineering or giving orders.
  • Remember that those with wounds from emotional trauma need help as much as physical trauma victims.

The nurse

  • Healthy diet, sleep, exercise, and other de-stressing skills are crucial to have the patience and emotional energy to speak slowly and kindly to those who are not behaving in a way to deserve it and who require 110% of your attention.
  • Allow enough time between work shifts for rest, relaxation, quiet meditation, reading, prayer, and reflecting so you can renew your capacity to address stressful situations.
  • Understand and care about our hurting colleagues who may respond under stress in ways that are based on past unrelated experiences.

The workplace

  • Adequate staffing is critical to keep nurses from becoming too busy to address patient and visitors’ perceived needs and to have the time to de-escalate volatile situations rather than have the person feel abandoned or neglected, which could escalate violence. Enough staff is needed so no nurse is left alone in a potentially dangerous situation.
  • Adequate security is needed with both security officer presence and a secure environment including panic buttons in strategic locations, lighting, security doors, card access, and locks where needed. Nurses must feel safe enough to do their work efficiently and confidently. Appearing fearful could escalate violence.
  • Time needs to be provided for team building and support groups away from the stressful work environment.
  • Nurses who become overly stressed or victimized need the option for a respite break, counseling, and other appropriate assistance.
  • Food service needs to be easily accessible to patients, staff, and visitors. Food can de-escalate, while low blood sugar can escalate problems.
  • Nurses need to report incidents and have input into violence prevention and security. Administration needs to support nurses when they report violence concerns.

Society

Violence in health care settings is a reflection of violence in society. As more and more people become victims such as through human trafficking, terrorism, wars, or as children suffer serious neglect such as by parents who are addicted to substances, increased violence should be anticipated.

What can nurses do about a violent society?

  • Advocate for adequate mental health services. The number of people who are incarcerated has increased exponentially simultaneously with the closure of mental health facilities nation-wide and the decrease in long-term neurological rehabilitation. Up to 90% of prison inmates could have neurological and/or neuropsychological conditions. People with mental health conditions were moved from prison to mental healthcare settings during the late 1800s because of nurses such as Dorothea Dix. Yet society has now moved backward with the closing of those mental healthcare settings in recent decades, including the facility named after Dix.
  • Advocate against violent role models in neighborhoods or through media such as television, movies, internet, and video games. This is particularly critical during neurodevelopment years until the age of at least the mid-20s. People can become so desensitized to violence that they see it as a normal part of life. This was a very prevalent theme in my research with prison inmates. Prisoners were incarcerated because they acted in ways they were taught by adults around them when they were children.
  • Be a role model. Provide positive community alternatives to violence such as youth groups for mentorship to encourage children to consider healthcare professions and other healthy activities. Teach proper childcare and encourage older children to be positive role models for younger children.
  • Report child abuse as soon as it is recognized, refer victims for assistance as early as possible, and remember that perpetrators are most likely also victims of childhood abuse. Laws and fines for failure to report child abuse vary from state to state.

Nurses take the lead

Nurses are at the forefront interfacing with violence victims and perpetrators. Nurses are trusted professionals in society who can make a difference in decreasing violence within one’s sphere of influence at the bedside, in the community, and worldwide.

Selected references

American Nurses Association. Bullying and workplace violence. http://www.nursingworld.org/MainMenuCategories/WorkplaceSafety/bullyingworkplaceviolence August 2015.

Barrett EL, Teesson M, Mills KL. Associations between substance use, post-traumatic stress disorder and the perpetration of violence: a longitudinal investigation. Addict Behav. 2014;39(6):1075-80.

Brewer-Smyth K, Burgess AW, Shults J. Physical and sexual abuse, salivary cortisol, and neurologic correlates of violent criminal behavior in female prison inmates. Biol Psychiatry. 2004;55(1):21-31.

Brewer-Smyth K, Burgess AW. Childhood sexual abuse by a family member, salivary cortisol, and homicidal behavior of female prison inmates. Nurs Res. 2008;57(3):166-74.

Centers for Disease Control and Prevention (CDC) Workplace Violence Prevention for Nurses www.cdc.gov/niosh/topics/violence/training_nurses.html. November 2014.

Dumont DM, Brockmann B, Dickman S, et al. Public health and the epidemic of incarceration. Annu Rev Public Health. 2012;33:325-39.

Gillespie GL, Gates DM, Miller M, et al. Workplace violence in healthcare settings: risk factors and protective strategies. Rehabil Nurs. 2010;35(5):177-84.

Hanrahan NP, Stuart GW, Delaney KR, et al. Mental health is an urgent public health concern. Nurs Outlook. 2013;61(3):185-6.

Jonson-Reid M, Kohl PL, Drake B. Child and adult outcomes of chronic child maltreatment. Pediatrics. 2012;129(5):839-45.

Kelen GD, Catlett CL. Violence in the health care setting. JAMA. 2010;304(22):2530-1.

Kuehn BM. Violence in health care settings on rise. JAMA. 2010;304:511-2.

McPhaul KM, London M, Lipscomb JA. A framework for translating workplace violence intervention research into evidence-based programs. Online J Issues Nurs. 2013 18(1). http://nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Vol-18-2013/No1-Jan-2013/A-Framework-for-Evidence-Based-Programs.html

National advisory council on nurse education and practice, Violence against nurses: http://www.hrsa.gov/advisorycommittees/bhpradvisory/nacnep/reports/fifthreport.pdf. December 2007.

Papa AM, Venella J. Workplace violence in healthcare: Strategies for advocacy. Online J Issues Nurs. 2013 18(1). http://nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Vol-18-2013/No1-Jan-2013/Workplace-Violence-Strategies-for-Advocacy.html

U.S. Department of Labor, Occupational Safety & Health Administration. https://www.osha.gov/SLTC/workplaceviolence/.

Kathleen Brewer-Smyth is an associate professor in the School of Nursing, College of Health Sciences, University of Delaware, in Newark, Delaware.

 

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