It has happened again. On October 22, 2022, workplace violence claimed the lives of two healthcare professionals from Methodist Dallas Medical Center in Texas. It's a shocking tragedy that, according to reports, unfolded in the center's labor and delivery unit, where recovering new mothers rest under the watchful eyes of their healthcare teams. Both victims were providing care at the time of the shooting. It's safe to assume that today, and for the foreseeable future, the families and colleagues will mourn the victims and will ask, "How could this happen?" Unfortunately, healthcare workers are all too often the victims of workplace violence. It's a puzzling reality that begs for solutions. More often, healthcare workers including nurses are the front-liners that care for the victims of violent acts such as mass shootings. Both scenarios are traumatic for the cared for and the caregivers. When Alisha Cornell, DNP, RN, heard about the shooting of 19 students and two teachers in Uvalde, Texas, on May 24, 2022, she was overwhelmed with emotion. [caption id="attachment_104733" align="alignleft" width="250"]
Alisha Cornell, RN[/caption] The former trauma nurse was transported to her days at the bedside when she faced unexpected tragedies: patients who had been involved in serious accidents, violent attacks, or other events. "When I experience a triggering event, it feels like the shootings are happening around me at that moment," said Cornell. Nurses throughout the country have been affected by the news of recent mass shootings, including the deaths of 10 Black shoppers at Tops Friendly Markets in Buffalo, New York, on May 14. Two weeks later, three hospital staff and one patient died in a shooting on the Saint Francis Hospital campus in Tulsa, Oklahoma.
"For nurses with young children, nurses of color, or nurses working in hospital systems like the one in Tulsa, just hearing about these events can cause some secondary or vicarious trauma," said Nellie Galindo, MSW, MSPH, a Product Marketing Manager for Relias who specializes in trauma-informed strategies. "That's why it's so important for nurse supervisors to be aware of the symptoms of secondary trauma and burnout."
These symptoms include feeling disconnected or distant from patients and co-workers, nightmares, flashbacks, depression, anxiety, oversleeping, or feeling overly lethargic. [caption id="attachment_104735" align="alignright" width="250"]
Felicia Sadler, RN[/caption] "The recent tragedies have highlighted the need for meaningful strategies to halt these events," said Felicia Sadler, MJ, BSN, RN, CPHQ, Vice President of Quality for Relias, who has experience as an ICU nurse. "Violence in healthcare comes in many forms -- both inside and outside our four walls."
Violence in the Workplace
Although nurses were not involved in the recent mass shootings, they are at risk of experiencing violence from patients, former employees, people who have a personal relationship with them, or perpetrators who have no association with the nurse or healthcare facility. The rate of workplace injuries as a result of violence is higher among healthcare workers than any other profession. The incidence of violence against hospital employees has increased since the onset of the pandemic, with 44% of nurses reporting an increase in physical violence, and 68% reporting an increase in in verbal abuse, according to recent data from the American Hospital Association (AHA). To honor nurses and advocate for change, thousands of nurses gathered in Washington, D.C., in May to demand reforms in the healthcare industry, such as fair wages, safe staffing ratios, and protection against workplace violence.
"Prevention is key," said Sandra Risoldi, DNP, MSN, Ed, APRN, PMHNP-BC, Founder and President of Nurses Against Violence Unite Inc., who spoke at The Nurses' March in the nation's capital in May. "It is vital that we prevent problems before they get worse."
Nurses are also hoping the U.S. Senate will pass S.4182, the Workplace Violence Prevention for Health Care and Social Workers Act, which was introduced in May 2022. It passed the U.S. House of Representatives as H.R. 1195 in April 2021. The bill would require employers to develop and implement comprehensive workplace violence prevention plans. "It's very traumatic to be assaulted at work and to have no repercussions for the person who assaulted you," said Janice Maloof-Tomaso, MSN, RN, NEA-BC, who spoke in a video at the Nurses' March. Workplace violence is another factor that can lead to burnout among nurses, and Maloof-Tomaso will be speaking at an upcoming symposium on Wednesday, June 22, focused on burnout risk factors and prevention strategies. She will discuss moral injury and redefining traditional clinical burnout. [caption id="attachment_104749" align="alignleft" width="250"]
Nellie Galindo, MSW[/caption]
Trauma-Informed Supervision
Whether nurses are personally experiencing violence at work, are treating victims of violence, or are hearing about tragedies in the news, leaders can support staff by incorporating trauma-informed supervision practices into daily interactions, said Galindo. "Trauma-informed supervision breaks down the traditional hierarchy of manager-to-employee and emphasizes open, honest feedback between all parties," she said. According to the Relias article, "Trauma-Informed Supervision: Building Strong Relationships and Organizations," by Anole Halper, MSW, MPH, trauma-informed supervision involves the following principles: safety, trustworthiness and transparency, peer support, collaboration and mutuality, empowerment, voice, and choice, and cultural historical and gender issues.
| Trauma-Informed Care Principle | Meaning | How It Applies to the Supervisory Relationship |
| Safety | Ensure physical and psychological safety in the environment and relationships. Persons served (not the organization) determine whether safety is achieved. | Focus on a sense of safety for staff. Defer to nursing staff to define it. |
| Trustworthiness and Transparency | Make decisions transparently to ensure survivors feel included in the process. | Share transparently with staff about why and how decisions are made. Communicate regularly, openly, and honestly. |
| Peer Support | Other individuals with lived experiences of trauma are valuable resources for support and hope. Create opportunities for peer support and connection. | Make time and space for staff members experiencing traumatic stress to support each other. |
| Collaboration and Mutuality | Level power differences among different nursing staff members. | Rather than tell staff what to do, collaborate with them to determine and meet goals. |
| Empowerment, Voice, and Choice | Acknowledge trauma survivors' strengths by ensuring they have a voice within the organization and a treatment plan. | Listen to feedback from nursing staff. Offer positive support, encouragement, and tools. Facilitate rather than dictate. |
| Cultural, Historic, and Gender Issues | Recognize and address biases. Ensure policies and practices respond to the unique cultural, racial, and ethnic needs of the community you serve. | Recognize how factors such as historical trauma, racial trauma, discrimination, and culture impact nurses' experiences of their work. |
Regaining Power
Trauma in any setting is an experience of disempowerment, and nurse leaders who share power with nursing staff can prevent and undo traumatic stress. Here are examples of how to share power through trauma-informed supervision:
- Hold regular supervision at a time and place that works for you both. Collaboratively create an agenda. Ask, "What would you like to discuss today?"
- Transparently explain your availability and boundaries (outside of supervision sessions). "Thursdays, I focus on projects. But you can email me anytime, and if I'm not available, I'll get back to you the next day."
- Listen non-judgmentally, openly, and empathetically. "I know this patient's case would be very difficult for anybody. Would you like to start there?"
- Use humility and self-disclosure to create an emotionally safe environment for nursing staff to share.
- Validate struggles and successes. "It sounds like that patient made an inappropriate remark. But I'm impressed that you respectfully set boundaries."
- Work with nursing staff to arrive at solutions. "I'm wondering if you have any thoughts about how to move forward. What support do you need?"
- Work together to create goals, and find the best ways to meet them.
New Crisis Hotline Available: Beginning July 16, 2022, the 988 crisis hotline will be fully operational. Those across the United States who are witnessing or experiencing a mental health crisis can call the hotline to speak with a trained counselor. Editor's note: This post was originally published on June 14, 2022, and has been updated with new content.
Take this course to learn more:
Active Shooter Response
(1 contact hr)
The goal of this course is to educate healthcare professionals in all settings about specific actions for assessing the risks for an active shooter event, as well as actions to take to prevent and respond to these incidents.
After taking this course, you should be able to:
- Review definitions, statistics, and trends of active shooter events.
- Explain the natural responses of the human body when exposed to danger.
- Evaluate and discuss ways in which training and preparation can be incorporated into institution protocols.
