The Registered Nurses’ Association of Ontario (RNAO) takes a ‘Zero Tolerance’ approach to violence in the workplace. RNAO believes that all nurses have the right to practice in a supportive environment where workplace violence is not tolerated.
Employers have a responsibility to implement policies, procedures and practices that promote safety and the well-being of nurses. Governments have a responsibility to fund and support work environments that promote safety and well-being.
Workplace violence frequently occurs in health-care environments. Although the definition of violence varies depending on practice settings or situations, there is agreement that violence in the workplace is detrimental to the health and well-being of nurses and to the provision of quality nursing care. Workplaces include hospitals and long-term care facilities, as well as practice settings in the community such as primary care sites, outreach services, educational institutions, and clients’ homes.
Definition of Workplace Violence
This policy statement defines workplace violence as ‘an incident of aggression that is physical, sexual, verbal, emotional or psychological that occurs when nurses are abused, threatened or assaulted in circumstances related to their work’.
It is estimated that 50 per cent of health-care workers will be physically assaulted during their professional careers, [iv] and nurses are three times more likely to experience violence than any other professional group.Given that nurses constitute 58.3 per cent of Ontario’s health-care workers, the impact of workplace violence on nursing and the delivery of nursing care is significant. Nurses experience emotional distress and physical injuries – and in more serious instances, permanent disability or death – as a result of workplace violence. In one study, the cost of workplace violence against nurses, including absence from work, emotional distress, and medical expense, was estimated at about $35,000 per assault-related injury.
Nurses working in all sectors of health care are at risk for violence. Findings from the 2005 National Survey of the Work and Health of Nurses showed that in Ontario 28.4 percent of respondents had been physically assaulted by a patient in the previous twelve months and 2 per cent had been physically assaulted by someone other that a patient. In the same survey, the percentage of Ontario respondents who reported they had experienced emotional abuse at work, over the past 12 months was: from a patient, 44.9 per cent; from a visitor, 16.9 per cent; from a physician, 8.7 per cent; from a nurse co-worker, 10.3 per cent; and from someone else, 9.0 per cent.
Nursing students have similar experiences to registered staff including experiencing horizontal violence. This can influence a student’s decision to remain in the profession. Also, there is concern that students may begin to assimilate this conduct into their practice, perpetuating the behaviour.
Faculty are also known to experience uncivil encounters with students. These are concerning as these experiences have caused some to leave teaching. This leads to a shortage of educators, and aggravates the shortage of nurses by reducing the ability of programs to take in students.
Recruitment and retention in the Ontario nursing workforce is a major concern for government and nursing organizations. With 21.3 per cent of the nursing workforce eligible to retire as of 2005, issues of retention and recruitment are even more pressing. Violence in the workplace directly impacts the number of individuals who enter or remain in the nursing profession.
Violence toward nurses originates from multiple sources and risks are multifaceted. It is important to take a broad approach, examining societal, workplace, and individual factors, and recognizing the dynamic relationship between them.
Acts of direct violence against individuals may be most usefully understood within the context of structural and cultural violence. Structural violence refers to any constraint on human potential due to economic and political structures. Structural inequalities in access to resources and political power create inequitable access to opportunities.[vii] A lack of social justice may be equated with structural violence. Cultural violence is any aspect of a culture that can be used to legitimize violence in its direct or structural forms. For example, elements of patriarchal cultures can support the idea that women are less valuable than men, so striking them or paying them less than their male counterparts is somehow acceptable. At the individual level, structural violence, and the cultural violence that makes it possible, is manifested in various forms of direct or overt violence. These include:
A number of factors contribute to violence in the health-care workplace depending on practice setting. Some of these include:
Forms of Violence Against Nurses
Clients and families are involved in the majority of incidents of violence toward nurses. Situations and individual risk factors most likely to elicit violent or abusive behaviour toward nurses include:
Physicians have been cited as the major source of verbal abuse that nurses are subjected to on almost a daily basis. This form of abuse often arises out of power differentials between physicians and nurses. These power differentials are related to two main factors:
Nurse to nurse, nurse to nursing student and nursing student to nurse violence is often ignored or downplayed by both nurses and institutions. This form of violence is often referred to as ‘bullying’ or ‘interpersonal conflict’. Nurses experience this form of violence as a routine part of their work life. While explanations for this vary, they include:
RNAO calls for the development and implementation of specific strategies to prevent and stop violence against nurses in the workplace. Recommendations from societal, organizational, and individual perspectives include:
Specific to Institutions
All recommendations under organizations plus:
Specific to Community Settings
All recommendations under organizations plus:
Universities and Colleges
RNAO takes a ‘Zero Tolerance’ approach to workplace violence. It is important to ensure safe practice settings for all health-care providers, and imperative that violence is addressed from a societal, organizational, and individual level.
Please see the pdf version of this document  for footnotes and references.
Revised September 2008