Occupational violence and aggression is rife within the healthcare sector. The impact of verbal and physical assault can leave psychological scars that lead many to question their place in the workforce. Growing public awareness, harsher penalties for perpetrators, and improved safety strategies mark a shift towards a culture of zero tolerance and collective attitude that enough is enough. Robert Fedele investigates.

Registered Nurse Lita Olsson was 30 weeks pregnant when an intoxicated and disoriented middle-aged man struck her to the chest as she was carrying out routine nursing care.

The incident, which occurred in the emergency department (ED) at Royal Brisbane and Women’s Hospital, left Lita scarred. “At the time there was a lot of talk about whether or not to press charges and it was quite a contentious issue. This was about five years ago. We didn’t quite have the relationship that we do now with security and police.”

Lita has been a nurse for 11 years and worked in ED since 2007.

She says workplace violence and aggression in hospitals is widespread.

Incidents like nurses being spat at or bitten, having urine thrown at them, or more worrying scenes involving nurses being cornered or pulled into rooms, is nothing out the ordinary, she says. “ I don’t know a person who hasn’t been threatened or verbally assaulted or had some sort of near miss with a physical assault. At the moment we’re trying to change that culture around the fact that it’s not acceptable.”

The Royal Brisbane and Women’s Hospital has made significant inroads over the past few years by empowering nurses to report assaults to police and Lita believes that changing culture has helped build the capacity to capture more accurate data.

Progression towards a zero tolerance approach was initially sparked by several incidents within the department where staff were subjected to ongoing threats over consecutive days and were later to complete their shifts due to feeling scared and victimised.

“From that, we really took a stand as a department and banded together to try and change the culture that if it’s not a life-threatening issue then it’s not acceptable and they won’t be treated,” Lita said.

The Queensland government has jumped on board the push and earlier this year launched a $1.35 million public awareness campaign to stop violence against hospital staff and paramedics. Figures show that last year, more than 3,300 healthcare workers were physically assaulted across the Queensland workforce.

More than 300 incidents have already been recorded in Royal Brisbane and Women’s Hospital’s ED this year, a statistic Lita labels “just the tip of the iceberg”.

The public campaign features confronting advertisements of healthcare workers being verbally and physically assaulted while on the job.

“To be fair, it might be a bit sanitised,” Lita suggests. “As scary as it sounds, it’s not far from the mark. I’ve seen those sorts of incidents happen. It’s scary.”

A recent strategy implemented by the Royal Brisbane and Women’s Hospital in a bid to capture data that exposes the problematic issue has been a swipe card reader mounted to a wall in the middle of the ED. When an assault occurs the card is swiped in real time and the information is later used to pinpoint peak periods and help shape future strategies.

Lita welcomed the government’s public awareness campaign and says education plays a crucial part in unlocking the puzzle. “It’s certainly a step in the right direction but I think we’ve got a long way to go. When you talk to the general population they’re actually unfamiliar with how often it does happen.”

Lita is Acting Clinical Nurse Consultant within Royal Brisbane and Women’s Hospital ED. She is also the department’s central liaison and sits on Royal Brisbane and Women’s Hospital Aggression Taskforce, a committee formed to address issues, mitigate risks, and altogether keep nurses, doctors and patients safe within the hospital.

The 32-year-old mother of two was compelled to become an advocate on the issue after returning from maternity leave and uncovering the escalation in alcohol and drug-fuelled violence pervading in the ED.

She believes change can occur if collective standards are embedded in culture. “The only way we’re going to say we have a zero tolerance approach is if we actually have zero tolerance. It’s following through with the actions about not accepting that behaviour.”

Spotlight on assaults
In Tasmania, Registered Nurse Deanna Butler holds the role of Clinical Coordinator and Navigator within the Royal Hobart Hospital’s ED.

In the same vein as Lita, Deanna says life in emergency can be dangerous. “You’re vulnerable. You’re at risk of being hurt. And nobody likes to be abused. As much as words don’t hurt, standing in a full room, there can sometimes be 40 people in the department and it’s like a scene at the pub sometimes. It’s demanding.”

Deanna agrees all hospitals should be enforcing zero tolerance to counter workplace violence and aggression. “I remember when I first started in emergency it was quite frightening when you’re coming through the ropes, there was one lady who was a mental health presentation and she just became very aggressive in the department and began throwing a water bottle around which nearly hit one nurse and then continued to go around the department and smash a computer and throw other things around.”

Deanna recalls another incident where a patient affected by Ice became violent and aggressive and smashed up an X-Ray machine before the police were called.

While the Ice epidemic poses a major issue across Australia, Deanna argues alcohol is the biggest cause of workplace violence in hospitals.

Recent finding from a large-scale study investigating eight emergency departments across Australia and New Zealand in 2014 conducted by the Australasian College for Emergency Medicine (ACEM) revealed that at peak times, one in eight presentations was cause by alcohol.
The study found verbal aggression from a patient has been experienced in the past year by 97.9% of survey respondents, and physical aggression by 92.2%.

A significant 87% said they felt unsafe in the presence of alcohol-affected patients and 42% had often of frequently experienced physical aggression from alcohol-affected patients.

Women were more likely to experience frequent verbal and physical aggression from alcohol-related patients at 69.1%.

The hidden toll of violence and aggression caused by alcohol-fuelled patients contributes to a negative impact on staff workload, wellbeing and job satisfaction, the study found.

Deanna concurs, suggesting aggressive incidents within the ED occur daily. But she says incidents emerge from all corners, including delirious patients hitting out, or concerned relatives lashing out at staff while waiting on news about their loved ones. “They might not believe that they should be waiting or they could become upset with things. A lot of the time that’s anxiety and where our communication probably needs to be a bit better.”

At Royal Hobart the ED is always staffed with security and Code Black teams are on hand to respond to escalating incidents involving threats to staff with weapons.

“If it’s people who’ve been medically unwell I guess we tolerate it a bit more. We’re not there to get abused but we are there to help them get better to manage that,” Deanna explains. “We do get a little bit more upset when it’s the drugs and alcohol. It’s when people are aware of what’s what and what’s wrong and they are still aggressive towards you. It’s that situation that we get scared about because we are more vulnerable and they’re people in society who don’t care about their lives so they’re not going to care about what they’re doing to us.”

The scourge of Ice and alcohol
Professor Gordian Fulde is the Director of Emergency at St Vincent’s Hospital in Sydney, arguably one of Australia’s busiest EDs.

A longstanding advocate against the scourge of Ice and alcohol fuelled violence that triggers a flood of people into Australian hospitals each weekend, Professor Fulde was named the Senior Australian of the Year for 2016 largely due to his tiresome work to solve the issue.

“For a while there, in the bad old days, it was considered part of your turd,” Professor Fulde explains. “In other words, a person out of control who knew what they were doing smashed the walls, broke equipment, punched the staff, and you couldn’t take anybody to court because the government wouldn’t let you do anything. Thank heavens that’s turned around.”

Indeed, times have changed, with lengthy jail terms of up to 14 years now in place across several states for people who commit violence against health professionals.

Framing the debate, Professor Fulde says the equation is simple: nobody should have to go to work and feel threatened.

Conducting his own research into the issue, he found the size of a person matters when it comes to violence. “If it was a small person, a nurse of doctor, at 3 o’clock in the morning, and it’s someone drunk and out of control, they’re more likely to be nasty to a small person than a big person.”

In Professor Fulde’s workplace, the often volatile St Vincent’s, which has been captured in the TV series Kings Cross ER, considerable safety measures have been implemented to curb occupational violence. “There’s still a ways to go. In my department, the security staff are fantastic and they literally put their bodies on the line for us.”

Asked to consider the impact of the drug Ice, Professor Fulde says it’s influence is wide-ranging and effects unpredictable.

“The most horrible thing about crystal meth and these sorts of things, cocaine too, is that somebody could be nearly okay, eye contact, talking to you, and within a nano-second, they can go absolutely crazy.”

Professor Fulde disputes some areas of research, largely survey-based, that indicate a drop in Ice use.



“Our experience says there’s more people taking Ice and it’s going up. The reality is it’s everywhere. Rural, city, the house next to you. Ice is the most profitable drug there is. It’s effects are devastating.”

The latest statistics from the National Drug and Alcohol Research Centre (NDARC) support his claims and show almost 270,000 Australians are regular users of Ice, with one in 100 addicted to the harmful drug, and that use has increased in the past five years and remains highest among young people under the age of 34.

Professor Fulde says the bulk of Ice-affected patients rolling through doors present with paranoia and agitation rather than being completely wild and berserk as some may believe.

The culture of violence and aggression against health professional is crippling, says Professor Fulde. “What is affects is morale. Nurses will not work. If you had a brother, sister, daughter, and you hear they were hit you’d go ‘get the hell out of there’ wouldn’t you?”

Professor Fulde does not concede societal expectations regarding violence towards healthcare professionals is changing and that a greater willingness to tackle the issue has developed. In his view, the changes must evolve from the grassroots up and local solutions found to confine problems. “The government can help over-archingly but in the first instance these things need to be looked at locally and then escalated as needed.”

Enforcing zero tolerance
Positively, violence and aggression towards health professionals is being tackled in significant ways across the country.

In 2014, the Australian Nursing and Midwifery Federation (ANMF Victorian Branch) adopted a 10-point plan to end violence and aggression, flagging actions to increase security, implementing proactive measures to identify and address risk, and improving reporting culture and support mechanisms.

The comprehensive strategy came on the back of legislation introducing harsher penalties for those harming healthcare workers, and a Monash University study found 70% experienced violence and aggression in the past year.

A similar plan was more recently adopted in New South Wales earlier this year in direct response to increasing aggression and violence across the state’s hospitals, including the double shooting of a security guard and police officer outside Nepean Hospital in Sydney’s west in January.

A roundtable in February endorsed a 12-point action plan to curb the issue, with strategies involving regular security audits of dozens of EDs, establishing a working group to recommend lines of attack and delivering an intensive training program for ED staff including nurses so that they learn to manage aggressive behaviour.

The New South Wales Nurses and Midwifes’ Association (NSWNMA) has also released an app where nurses can report and log workplace violence as soon as it occurs.

In NSW, a Parliamentary Inquiry is also currently being conducted into Violence Against Emergency Services Personnel, including nurses.

The Committee on Law and Safety will examine the adequacy of current practices tackling violence, the benefit of training and public awareness campaigns, and whether current sentencing options for people who commit assaults remain effective. South Australia is another state taking a stand.

ANMF (SA Branch) CEO/Secretary Adjunct Professor Elizabeth Dabars says occupational violence against nurses is an “age old problem’ that’s continued to escalate. “It’s important to remember that it’s not just confined to emergency departments. Certainly emergency departments bear a significant runt but there is violence and aggressive acts in any area in which a nurse or midwife works.”

South Australia’s historic shortcoming in tackling the issue are improving gradually.

Changes to legislation in recent years ensuring successful prosecutions result in more serious penalties have been welcomed, albeit countered by a perceived reluctance to prosecute people engaging in violent acts.

Similarly, while South Australia Health has encouragingly released a Challenging Behaviours Policy aimed at minimising potential harm to healthcare workers, a lack of true implementation lingers.

“We have been both welcoming of that but also somewhat critical because we want to see not just the creation of these policies but implementation of it and real results, not just platitudes of the fact you’ve done this,” Ms Dabars says.

According to Ms Dabars real progress has included support in exploring the establishment of designated detox areas for patients who are drunk or under the influence of drugs. A public awareness campaign is in the pipeline to educate to community that violence and aggression towards healthcare workers should not be tolerated. The ANMF (SA Branch) is also working with SA Health to try and pinpoint statistics surrounding aggressive and violent acts in order to properly gauge the success of strategies released a year ago. “I believe at the moment that the success or otherwise of that strategy can only be called patchy. The statistics so far show there has been some decrease in violent and aggressive acts in some areas but increases elsewhere. So there is a significant amount of works that needs to occur,” Ms Dabars says.

A key area of ongoing debate within the issue surrounds the potential for a mental health condition contributing to a patient’s actions and blurring the law when offenders are prosecuted, says Ms Dabars.

Ms Dabars stresses that being drunk or drug affected is no ground for a defence and that it is also inappropriate to use a mental health condition as an excuse on all occasions. “I think we need to move beyond that and say well at the end of the day the person has committed a violent and aggressive act.

“There’s certainly people who do have mental health conditions who still have control over their actions. We need to break down those myths and those barriers and make sure that as much as possible we prevent and deter these kinds of behaviours but in the event that they do occur, that appropriate penalties apply.”

Ms Dabars says violence and aggression must end and that all health professionals “have an absolute right to a safe working environment.”

Leading change
“Right now, tonight, there’s probably over a hundred remote area nurses (RANs) out there by themselves, alone and vulnerable, and a lot more scared than they were since Gayle [Woodford’s] death,” Remote Area Nurse (RAN) Kate Chapman says.

Ms Woodford, a remote area nurse from South Australia, was tragically murdered in late March, with her death sparking national interest and renewed calls to tackle enduring safety challenges facing the rural and remote health workforce.

In May, Kate accompanied ANMF’s Assistant Federal Secretary Annie Butler and Senior Federal Professional Officer Julianne Bryce in visiting Rural Health Minister Fiona Nash to outline challenges and canvass strategies moving forward.

“I felt that she was engaged and supportive. She was interested. She was asking questions and she had a few things clarified,” Kate says. “She was surprised we weren’t calling the police if someone was verbally abusing us whereas we think that’s amusing because at times we have difficulty getting the police when we are having a physical altercation.”

Undoubtedly, aggression and violence can occur in any health setting, with the total and remote sector perhaps the most vulnerable due to isolation. Kate says she believes the voices of RANs are being heard, and with the backing of the ANMF, the workforce feels reassured that progress is slowly unfolding.

At a recent meeting of the ANMF federal Executive in May, the ANMF acknowledged the alarming issue of occupational violence and aggression and demanded it be allocated national importance.

The ANMF believes the issue should be placed on the agenda of the Council of Australia Governments (COAG), so that health ministers, in consultation with key stakeholders, can develop and implement a national strategy in response to the growing problem.

Kate, who has been a RAN for the past six years and loves the autonomy and diversity of the role, says occupational violence is part and parcel of the job. “With verbal abuse it’s at least daily. Physical abuse is pretty prominent and sexual violence is increasing.”

Kate lists the rise in Ice use and longstanding alcohol issues as the major causes behind occupational violence in rural and remote. “I think we’re more at risk. We’re more isolated. We’re sort of stuck between a rock and a hard place. If someone’s yelling at us and demanding something, if you’re on your own, if you ignore them or don’t respond, they very well might rock your house or try and get in. You’re going to make them angrier.”

Kate says working on call as a RAN means you often attend scenes despite safety concerns. “You can’t refuse. You’ve got to think ‘what could happen?’ If something happens and you hadn’t responded you’re in big trouble. Not only could you risk your registration but, if you get blamed, you could suffer paybacks by family or community members. But also you’ve got to live with yourself. With a lot of RANs it’s their conscience. They’re not going to be able to sleep at night worrying about it so they go out.”

Kate says RANs were galvanised by the death of Gayle Woodford and are now taking a stand and knocking back single nurse posts. More and more nurses are sharing their horrific stories and accessing CRANAplus’ Bush Support Service. “Everyone’s quite traumatised because they know it could have been them,” she says. “There’s a real stand and we are uniting. We’re not taking posts when they’re not offering it. We’re demanding security. We’re not asking for another nurse, we’re asking purely for another set of eyes to keep us safer.”

Ultimately, it is clear that aggression and violence should not be tolerated in our health system. To combat the problem, health services must ensure safe working environments for staff and governments must inject funding to educate the public through comprehensive awareness campaigns.

The prevailing culture of violence and aggression in health settings is no longer acceptable and change is critical.

This article was reprinted with permission of the Australian Nursing and Midwifery Federation