N490 Module 7 assignment: healthcare and violence paper, a full sample

Alone at the Door: Client Violence Against Home Health Nurses and Why It Goes Unreported

Student Name

RN to BSN Program, Aspen University

N490: Issues and Trends in Professional Nursing

Instructor Name

Month Day, Year

Alone at the Door: Client Violence Against Home Health Nurses and Why It Goes Unreported

Violence against health care workers is now recognized as one of the most serious occupational hazards in nursing, and most of the attention it receives is focused on hospitals, especially emergency departments and psychiatric units. Home health nurses face the same hazard under very different conditions. They enter private homes alone, often in the evening, sometimes in neighborhoods they do not know, and they meet not only the patient but whoever else is in the house. This paper describes the scale of workplace violence in health care, explains what makes home care distinctive, examines evidence on why home health nurses underreport violent events, and proposes agency-level measures that follow federal guidance and the research findings.

The Scale of the Problem

Health care is among the most violent civilian workplaces in the United States. A national review of the problem reported that health care and social service settings account for roughly three quarters of the workplace assaults reported each year and that health care workers are several times more likely than workers in private industry overall to be injured by an assault at work (Phillips, 2016). The review also noted that most incidents are never reported, so official numbers understate the true burden.

Federal guidance classifies these events by the relationship between the perpetrator and the worker. Violence by patients, clients, or their visitors, called type II violence, is the most common form in health care (Occupational Safety and Health Administration [OSHA], 2016). It is also the form nurses are most often told to accept, because the person causing harm is someone the nurse is there to help.

What Makes Home Care Different

Home health care has been described as one of the fields with the highest rates of client violence, and the shift of care from hospitals into homes has put more workers into that setting each year (Campbell et al., 2013). The hazard is not only more frequent but structurally different. In a hospital, a nurse who feels threatened can step out of the room, call security, or ask a colleague to come in. In a home, the nurse is on the other person's territory, may be blocked from the only exit, and may have no one to call who can arrive quickly.

The threat also comes from more directions. A patient with dementia may strike out during personal care, a family caregiver under strain may become verbally abusive, and a visitor under the influence of alcohol may be present when the nurse arrives. Weapons, aggressive dogs, and unsafe neighborhoods add risks that hospital policies were never written for. Surveys of community nurses outside the United States show the same pattern: in one national sample of community nurses in Slovenia, more than half reported verbal abuse from patients within a single year (Gabrovec, 2017).

Why Violence Goes Unreported

Underreporting is the reason the problem stays invisible. A study at a U.S. nonprofit home health agency combined a survey of home health nurses, focus groups, and interviews with managers to understand when nurses report type II violence (Byon et al., 2020). The nurses generally reported the most serious incidents, and they were more likely to report when they believed it would help, for example by warning colleagues who would visit the same home, and when managers were supportive.

They were unwilling to report when reporting felt costly or pointless. Reporting meant reliving a frightening event, a shared belief that violence is part of the job discouraged it, the process was not standardized, and nurses were often unsure whether verbal threats or intimidation counted as reportable at all (Byon et al., 2020). Managers in the same study identified the lack of a standard reporting process as a barrier on their side too. When neither the nurse nor the manager is sure what should be reported, the agency cannot see the risk, and a home that frightened one nurse will be assigned to the next one without warning.

A Composite Visit

The visit below is invented to illustrate the research; no real agency, patient, or nurse is portrayed. A home health nurse makes an evening visit to change a wound dressing for a man recovering from surgery. The patient's adult nephew, who lives in the home, is intoxicated and angry that the visit is late. He stands in the hallway between the nurse and the front door, shouts, and says she should not come back. She finishes the dressing quickly, leaves, and sits in her car shaking. Nothing physical happened, she tells herself, so she documents the wound care and does not file a report. The next week a newly hired nurse is scheduled for the same evening visit.

Recommendations for Home Health Agencies

The federal guidance recommends a written violence prevention program built on five elements: leaders who commit to it and involve staff, a study of where the risks are, controls that reduce them, training, and good records (OSHA, 2016). Applied to home care, four measures follow. First, the agency should define reportable violence in writing to include threats, intimidation, and verbal abuse as well as physical assault, and offer a short reporting channel, such as a phone call or mobile form, completed the same day. Second, reported homes should be flagged in the scheduling system so that the next nurse is warned and a plan is made, such as a daytime visit, a two-person visit, or a meeting with the family about expectations.

Third, every nurse should carry a way to summon help and follow a check-in routine, such as a text on arrival and departure, with an agreed code word that tells the office to call for assistance. Training should include de-escalation and the explicit rule that a nurse may end a visit and leave whenever staying feels unsafe, with no penalty for the missed visit. Fourth, managers should respond to each report with a follow-up call to the nurse and a documented action, because the research shows that visible management support is what makes nurses report (Byon et al., 2020).

Progress can be tracked by the number of reports per month, which should rise at first as the definition broadens, and by the share of flagged homes with a documented safety plan before the next visit.

Conclusion

Workplace violence is a recognized hazard in health care, but home health nurses face it without the walls, colleagues, and security staff that shape hospital responses. The evidence shows that they experience frequent client and family aggression and that much of it goes unreported because the definition is unclear, the process is cumbersome, and the norm of tolerance is strong. Agencies can change all three. A clear definition, a quick report, a warning to the next nurse, and a manager who responds would turn a private frightening moment into information that protects the whole staff.

References

Byon, H. D., Liu, X., Crandall, M., & Lipscomb, J. (2020). Understanding reporting of type II workplace violence among home health care nurses. Workplace Health & Safety, 68(9), 415-421. https://doi.org/10.1177/2165079920910758

Campbell, C. L., McCoy, S., Burg, M. A., & Hoffman, N. (2013). Enhancing home care staff safety through reducing client aggression and violence in noninstitutional care settings. Home Health Care Management & Practice, 26(1), 3-10. https://doi.org/10.1177/1084822313497364

Gabrovec, B. (2017). Prevalence of violence toward community nurses: A questionnaire survey. Workplace Health & Safety, 65(11), 527-532. https://doi.org/10.1177/2165079917691767

Occupational Safety and Health Administration. (2016). Guidelines for preventing workplace violence for healthcare and social service workers (OSHA 3148-06R). U.S. Department of Labor. https://www.osha.gov/sites/default/files/publications/osha3148.pdf

Phillips, J. P. (2016). Workplace violence against health care workers in the United States. New England Journal of Medicine, 374(17), 1661-1669. https://doi.org/10.1056/NEJMra1501998