Violence in America is spilling into the workplace. A one in four chance exists that a worker will be either attacked, threatened, or harassed on the job.

In 1993, the Northwestern National Life Insurance Company conducted a survey on workplace violence. Below are some of their findings:

• Violence and harassment in the workplace are pervasive. The number of victims of physical attacks exceeds 2 million, whereas nearly 6 million have been threatened and 16 million harassed.
• Violence and harassment affect the health and productivity of victims and other workers. Victims, as well as other co-workers feel angry, fearful, stressed, and depressed after an attack or incidence of harassment. The degree of physical injuries resulting from attacks varies. Approximately 3 out of 4 people experience psychological distress. Most victims of physical attack and or harassment, and their co-workers, experience an increased desire for a job change.
• There is a strong relationship between job stress and workplace harassment and violence. Job stress can be both a cause and effect of workplace violence and harassment. Highly stressed workers experience twice the rate of violence and harassment than less stressed employees. Threats of violence are usually linked with higher burnout rates.
• American workers believe social issues are major causes of workplace violence. Major social issues causing violence are substance abuse, layoffs and firings, and poverty. Minor social issues causing violence are availability of guns, violence on TV and in the movies, and job stress and job-related conflicts.
• Harassers are usually co-workers or bosses, while attackers are more likely to be customers (patients or clients). Attackers and harassers are usually people the victim deals with on a daily basis. The individuals responsible for the most harassment at work are co-workers and bosses, while customers, clients, and patients account for the largest segment of attackers. Victims identify interpersonal conflict as the most likely reason they were harassed or threatened at work.
• Improved interpersonal relations and effective preventive programs can result in lower levels of violence and harassment in the workplace.

Not all incidents of violence and harassment are the direct cause of co-workers and bosses. The two primary outside sources of violence are those which pose a criminal threat or a personal threat.

Sources which pose a criminal threat usually have not close personal connection to the organization and are carried out by strangers. These people are motivated by economic or ideologic factors. Incidents such as these include robberies and terrorism (abortion clinic bombings). Prevention from criminal threats requires an effective physical security program.

Sources which pose a personal threat usually are former employees or non-employees with an emotional connection to the organization. Former employees may have been terminated from their position and are avenging a grudge. Non-employees may be rejected or jealous lovers, or unstable spouses who suspect a workplace affair. Regardless of the outside source of violence, organizations should look to the law for help in these instances.

The resolution to violence in the workplace is a WorkplaceViolence Program.  The program can be justified by examining the consequences of violence incidents on the job. Some consequences to be considered are as follows:

• Moral and productivity of all employees suffer, not just the victim.
• If a key employee is a victim of violence, day to day operations may be disrupted.
• News of violence can become a public relations issue. Negative attention is drawn to the organization which may frighten away customers, clients, and patients. Associates who do business with the organization may sever ties. Recruiting efforts to fill vacant positions may suffer.
• Liability is a concern since some type of litigation will most likely occur which will attempt to show the organization was somehow negligent in its approach to workplace violence.
• If the employee is at fault, the employer may be blamed. Claims may be made stating the organization was aware of the attacker's or harasser's behavior problems and failed to act to correct the problem. The employer may be accused of negligent hiring, negligent retention, or inadequate supervision.
• If customers, clients, or patients are at fault for inflicting violence, the organization may be accused of negligence for failing to provide security to their employees.

The first step in developing a Workplace Violence Program is to organize a crisis management team.  The team must be interdisciplinary in nature and consist of employees from management, human resources, security, risk management, and employee representative(s), as well as a legal advisor and a psychologist. Outside experts may have to be retained if the employee pool is not qualified for certain responsibilities. The team is charged with developing workplace violence policies and serves as the decision making body when issues arise or violent incidents occur.  The team must have full and active support of the executive management. Regular meetings are held to develop a Workplace Violence Program, and to continually review and revise once the program is implemented. Contingency plans for every possible workplace violence scenario should be developed.

Policies and procedures of the Workplace Violence Program should be carefully researched, easily understood, and committed to writing. These should be explicitly stated in a personnel manual. The manual should include procedures for employees to follow who are victims of actual or threatened violence, or who witness violent acts or are concerned about their development. Contingency plans need to be prepared and distributed to team members and other personnel who may be called on to make decisions during an actual incident of violence. These plans should be treated as confidential documents and should include the following: operational checklist; emergency contact lists; notification schedules; resource lists; and detailed operational plans.

The Workplace Violence Program also identifies and evaluates potential threats of violence for employees. Warning signs of impending violence are usually unrecognized or ignored.  Employees at all levels need to be trained to recognize and report danger signals which precede violence. In doing so, great care must be taken to ensure the rights and privacy of those involved are closely guarded.

An "at risk" employee prone to violence may exhibit the following:

• emotional instability or violent behavior
• signs of extreme stress
• undergoes profound personality changes
• feels victimized by supervisors or the entire organization
• makes threats or alludes to acts of workplace violence
• signs of extreme paranoia or depression
• displays behavior inappropriate to the situation at hand
• signs of drug or alcohol abuse
• involved in a troubled, work-related romantic situation

Trigger situations which serve as catalysts to push a violence-prone employee over the edge include:

• performance counseling sessions
• discipinary actions
• termination, including non-disciplinary lay-off
• non-selection for promotion or a desired position
• criticism or harassment from co-workers
• failed or spurned work related romance
• significant non-work related personal crisis

The ultimate goal of a Work Violence Program is total elimination of all work related violence.  A more realistic goal is to reduce the risk of workplace violence. The first step in preventing violence is for management to realize that a potential threat exists. A mechanism must exist for all employees at any level to report potentially violent people or situations. The reporting should be centralized for several reasons: (1) to ensure information will reach decision makers quickly; (2) serves to facilitate the identification of 'at risk' behavior patterns; and (3) data from separate sources on the same individual can be identified. Centralizing reports depersonalizes the reporting process. If the attacker or harasser is a repeat offender at different sites within the organization, the whole picture of abuse will not be realized unless it is reported to a centralized committee. If individuals report violent incidents only to their immediate supervisor, the incident is treated as an isolated event and the pattern of repeat offenses may not be realized.

Once identified, 'at risk' employees prone to violence must be evaluated and provided counseling or other help. In situations where the employee's conduct warrants termination, an evaluation should be conducted to document the behavior patterns. Pre-employment screenings may be helpful in revealing an employee's history of violent or disruptive behavior.

A compensable injury is one that occurs or arises as a result of a specific incident or accident within the course and scope of an individual's employment. Benefits arise as a matter of law and are paid either by the employer or the insurance company the employer has retained.

Injured employees have the right to be compensated for lost earnings incurred as a result of and injury on the job.  This is usually a temporary disability. The wage-loss compensation is a percentage of the employee's gross weekly salary and is provided while the employee is in the process of healing, unable to do any type of work throughout the healing stage. Sometimes temporary disability is awarded if the individual is able to continue the performance of light work.

Permanent disability is a work restriction caused by injury.  The employee receives compensation for the permanent inability to compete in the open labor market for a job. The compensation is dependent on the degree and severity of the permanent disability and the type of work the employee was doing.

Many states allow compensation for disfigurement and/or permanent loss of a bodily function. All treatments and examinations are at the employer's or insurance company's expense.

Individuals employed by state or private employers are covered by state statutes. Federal employees are covered by federal statutes.

Stress is defined as the demand made upon the adpative capacities of the mind and body. If the body can handle the demand and enjoy the stimulation involved, then stress is welcome and helpful.  If not, then stress is unwelcome and unhelpful. This definition of stress is useful in three ways: (1) stress can be both good and bad; (2) stress is not determined by events, but by how we react; and (3) stress is a demand upon the body's capacities, where if good, we respond well, and vice versa.

Some general causes of stress at work are:

• organization problems
• insufficient back-up
• long or unsociable hours
• poor status, pay, and promotion prospects
• unnecessary rituals and procedures
• uncertainty and insecurity

Some specific causes of stress at work are:

• unclear role specifications
• role conflict
• unrealistically high self-expectations (perfectionism)
• inability to influence decision-making (powerlessness)
• frequent clashes with superiors
• isolation from colleague's support
• lack of variety
• poor communication
• inadequate leadership
• conflicts with colleagues
• inability to finish a job
• fighting unnecessary battles

Some task-related causes of stress at work are:

• difficult clients or subordinates
• insufficient training
• emotional involvement with clients or co-workers
• responsibilities on the job
• inability to help or act effectively

The effects of too much stress are:

• concentration and attention span decrease
• distractability increases
• short- and long-term memory deteriorate
• response speed becomes unpreditable
• error rate increases
• powers of organization and long-term planning deteriorate
• delusions and thought disorders increase
• physical and psychological tension increase
• hypochondria increases
• changes in personality traits
• existing personality problems increase
• moral and emotional constraints weaken
• depression and helplessness appear
• self-estem falls sharply
• speech problems increase
• interests and enthusiasm diminish
• absenteeism increases
• substance abuse increases
• energy levels are low
• sleep patterns are disrupted
• cynicism about clients and colleagues increases
• new information ignored
• responsibilities are shifted onto others
• problems are 'solved' at superficial levels
• bizarre behavior patterns appear
• suicide threats may be made

Several exercises have been suggested to manage stress:

• learn and utilize relaxation breathing
• meditation
• water therapy: drink more water, swim, or relax in a bath
• learn relaxation programs
• change diet: less fat, more fresh fruits, vegetables, & fiber
• experience your emotions: cry, scream, laugh
• exercise regularly
• talk to someone
• learn to control your displaced aggressions: leave the job at work
• reappraise your life and priorities
• realize most stress is caused from within, not without

The term burnout became a buzzword during the mid 1970's. Definitions of burnout include the following:

• A syndrome of emotional exhaustion, depersonalization, and reduced personal accomplishment that can occur among individuals who do "people work" of some kind.
• A progressive loss of idealism, energy, and purpose experienced by people in the helping professions as a result of the conditions of their work.
• A state of physical, emotional, and mental exhaustion marked by physical depletion and chronic fatigue, feelings of helplessness and hopelessness, and the development of a negative self-concept and negative attitudes toward work, life, and other people.
• A syndrome of inappropriate attitudes toward clients and self, often associated with uncomfortable physical and emotional symptoms.
• A state of exhaustion, irritability, and fatigue that markedly decreases the worker's effectiveness and capability.
• To deplete oneself.  To exhaust one's physical and mental resources.  To wear oneself out by excessively striving to reach some unrealistic expectations imposed by oneself or by the values of society.
• To wear oneself out doing what one has to do.  An inability to cope adequately with the stresses of work or personal life.
• A malaise of the spirit.  A loss of will.  An inability to mobilize interests and capabilities.
• To become debilitated, weakened, because of extreme demands on one's physical and/or mental energy.
• An accumulation of intense negative feelings that is so debilitating that a person withdraws from the situation in which those feelings are generated.
• A pervasive mood of anxiety giving way to depression and despair.
• A process in which a professional's attitudes and behavior change in negative ways in response to job strain.
• An inadequate coping mechanism used consistently by an individual to reduce stress.
• A condition produced by working too hard for too long in a high-pressure environment.
• A debilitating psychological condition resulting from work-related frustrations, which results in lower employee productivity and morale.

Although each of these definitions are slightly different, there are common threads which run through each. All occur at an individual level and internal psychological experiences involve feelings, attitudes, motives, and expectations. Negative experiences concern problems, distress, discomfort, dysfunction, and negative consequences.  Exhaustion is depicted as the following: being worn out; loss of energy; depletion; debilitation; fatigue; physical or psychological loss of feeling, concern, trust, interest, and spirit; negative shift in response to others expressed as depersonalization, negative or inappropriate attitudes toward clients, loss of idealism, and irritability; and negative response toward oneself and personal accomplishments expressed as depression, low morale, withdrawal, reduced productivity or capability, or inability to cope.

What causes burnout? STRESS.

Burnout proceeds by stages that blend and merge into one another so smoothly the victim seldom realizes what happened even after it is over. Listed below are the 5 stages of burnout:

1. Honeymoon Stage - The job is wonderful. You have boundless energy and enthusiasm about the job.  You are delighted with the job, your co-workers, and the organization.
2. Awakening Stage - Your initial expectations about the job are unrealistic and the job does not satisfy your needs. You begin to realize your co-workers and the organization are less than perfect.  Rewards and recognition are scarce and you seem to be working harder to make your dreams come true.  You become increasingly tired, bored, and frustrated.  You begin to question your competence and start losing self-confidence.
3. Brownout Stage - Chronic fatigue and irritability are symptoms. Your eating and sleeping patterns change. Indulgence in escapist behavior occurs such as overindulging in sex, drugs, alcohol, food, shopping, or partying. You become indecisive, productivity drops, and your work deteriorates to the point where co-workers and superiors begin to comment. Frustration increases and you blame others for your difficulties. You become cynical, detached, critical of everything, depressed, anxious, and physically ill.
4. Full Scale Burnout - Despair is the dominant feature of this stage. You experience a sense of failure and a loss of self-esteem and self-confidence. You become pessimistic about the future. Physical and mental exhaustion occurs. Suicide, stroke, or heart attacks are not unusual.
5. Phoenix Phenomenon - This is the stage where you arise from the burnout. Rest and relaxation are necessary and you need to learn not to take work home with you. Be realistic in your job expectations, aspirations, and goals.  Try to create a balance in your life.

As health care professionals, the biggest risk we face everyday is exposure to infectious diseases. Our biggest defense against contracting these disease is the practice of universal precautions.

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References:

Paine, W.S. (1982). Job Stress and Burnout, Sage.

Jost, T.S. (1997). Regulation of the Healthcare Professions, Health Administration Press.

Fear and Violence in the Workplace.
URL: http://www.reliastar.com/z_tr_fear.html

Preventing Workplace Violence: Management Considerations. Gardner, R.A.
URL: http://www.protect-mgmt.com/expert/library/wpv.html

Stress. Fontana, D.
URL: http://www.hcc.hawaii.edu/hccinfo/facdev/Stress.html