Zero-Tolerance Policy: The Last Way to Curb Workplace Violence against Nurses in Iranian Healthcare System.

Dear Editor

Workplace violence (WPV), as a serious organizational issue worldwide, is defined as any violent acts including physical assaults and threats directed toward staff members at work or on duty.[1] The real size of the problem is largely unknown and the current knowledge is only the tip of the iceberg. Although it occurs in all working environments, but it’s a major challenge particularly for healthcare system administrators.[2] Although WPV occurs in every area of the healthcare system, nurses, as the largest members of the healthcare workforce and given their central role within the healthcare team, experience the greatest amount of WPV.[3] Indeed, nurses have been identified by the Australian Institute of Criminology as the occupational group who are most at risk of WPV.[2]

In the context of modern nursing practice, care is understood as a social contract between client and nurse that is undertaken in an environment of respect and reciprocity. From this perspective, WPV in the acute care setting has direct impact on nurses' ability and can be regarded as a behavioral barrier to the delivery of quality nursing care. Besides the destructive physical and psychological impact on nursing professionals, violence could directly and indirectly leads to immense financial loss in the healthcare system. Such consequences would also impact the organizational performance, nurses' well-being and productivity since all inevitably compromises the quality of care and puts healthcare provision at risk.[2,4,5]

A study in United States showed that 25% of emergency department (ED) nurses had been subjected to physical violence, over a year.[6] According to the study by the Emergency Nurses Association (2011), 53.4% of nurses reported experiencing verbal violence and more than one in 10 (12.9%) reported experiencing physical violence.[7] A systematic review carried out by Najafi et al., on WPV against Iranian nurses, also reported the frequency of violence in Tehran (verbal: 87%, physical: 28%), Tabriz (verbal: 72.1%, physical: 46.2%), Bandar-Abbas (verbal: 72.2%, physical: 9.1%), Zanjan (verbal: 77.4%, physical: 18.3%), Arak (verbal: 74.9%, physical: 7.38%), Hamadan (verbal: 64%, physical: 7%), Ilam (verbal: 89.8%, physical: 23.8%), Khorramabad (verbal: 78.5%, physical: 27.2%), Babol (verbal: 52.75%, physical: 15.06%), Urmia (verbal: 92.5%, physical: 34.2%), Rasht (verbal: 58.64%, physical: 11.11%); and concluded that prevalence of WPV against nurses in the hospital settings is unacceptably high, even with the current trend of under-reporting.[8] Another study among Iranian nurses has reported that 74.7% of them were subjected to psychological violence.[9]

Although many descriptive studies have been conducted in this regard, none of them has provided a rigorous approach to curb WPV against nurses.[2] Moreover, many studies conducted on the subject, “respect for patient rights”, few articles addressed the respect for the healthcare provider rights.[10] The healthcare providers charter of rights is provided in Iran based on the articles 608 and 609 of the section 15 and article 607 of the section 14 of the Iran's Islamic Penal Code (Book 5 – ta'zir crimes and deterrent punishments). It notifies that if everyone, including patients, their relatives and/or significant others insult to the healthcare personnel at work or on duty, will subject to the mentioned law.[11] Despite the law is passed years ago in Iran, unfortunately the government and management attitudes towards the issue had been too lax for many years, colluding with the widespread acceptance of the problem as ‘just part of the job’. Violence against nurses is frequently condemned in policy statements as an abuse of the human and occupational rights of such staff, but it’s not enough.

Accordingly, the higher risks of WPV against nurses attracts significant academic, legal, managerial, and governmental attention and concern and what clearly apparent is the need for an integrated approach,[12,13]addressing the training, administrative policies and procedures, security and environmental programs against WPV.[14] Consistent with these perspectives and to bring safety and security promptly to both physical and conceptual environments of the Iranian healthcare system, it’s necessary to deal with the administrative policies and procedures. Therefore, a strict commitment on tackling violence to nurses should be well-established on the Iranian government’s policy agenda for the Health Ministry. And as a government’s approach to this problem, it is to exhort nurses and their managers to adopt an attitude of “zero-tolerance policy” towards patients and their companions’ violence.

The implication of this policy is that all aggressive acts by a patient, including physical violence, threats, abuse and intimidation, should always be viewed as entirely negative and should not be accepted from anyone under any circumstances. The goal of establishing this policy for behaviors that undermine a culture of safety in caring organizations is to take the scare out of care and foster an emotionally safe and supportive working environment that can help nurses in the front line, both from an ethical standpoint and as a professional duty, return to caring about their profession, their patients, and each other and ultimately leads to the well-being of their patients. However, the new policy is not without its problems. One of these is the lack of clarity in defining the problem behavior of violence. The second problem with adopting zero-tolerance policy is that it may disturb the subtle balance which needs to be struck in deciding what is acceptable nurse and patient behavior in any healthcare interaction.[15]

So, to take effective steps, it’s a necessary requirement to organize a joint commission between officials of the Health Ministry, nursing associations, Judiciary, Legislature and Executive representatives to weigh up the possibility of setting zero-tolerance policy for controlling the epidemic of WPV against nurses in Iranian healthcare system.

Ethical issues

None to be declared.

Conflict of interest

The authors declare no conflict of interest in this study‏.