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verbal violence, nearly every hand will go up. Underreporting of vio- lence is a major obstacle to documenting the full extent of the problem. "We're pretty concerned that our nurses, in the emergency department in particu- lar, just don't report it anymore," said David Hughes, deputy general secretary of the Irish Nurses and Midwives Organization. "They just see it as something that is a normal hazard of their jobs. We don't agree with that." Kiejda likewise explained that nurses in her state were also not reporting violent incidents because nobody trusted the reporting system, which could be manipulated by the employer. "Management were able to change what the entries were," said Kiejda. "So you can see why people didn't report stuff." She said that New South Wales Health will in coming months pilot a new reporting system, which looks like an improvement and which she hopes RNs will consis- tently use. "At least what the nurses write will remain unchanged." Lastly, because upward of 90 percent of registered nurses around the world are female, workplace violence in nursing is by its nature a gendered problem. While both male and female nurses can, and do, suffer violence at work, the problem may be even more deeply entrenched and prevalent because of societal attitudes toward what is an acceptable way to treat women and what women themselves are socialized to tolerate. Jocelyn Andamo, RN and secretary general of the Alliance of Health Workers in the Philippines, relates that three nurse members working in a government hospital suffered "extreme psychological trauma" at the hands of a manager, who cut off the women's hair in public, both a physical and psychological assault. When nurses protested to the hospital director, he justified the manager's actions. "There is an atmosphere of fear so nurses are very afraid to speak up of their problems and complaints," wrote Andamo in an article about the workplace violence nurses in the Philippines experience. "Some describe the Filipino nurses' work- load as work like that of a mule or beast, as described locally as tra- bahong kalabaw, the water buffalo." * * * * * I n any discussion of workplace violence, it's critical to remember that the struggle for safety at work should not be separated from workers' general struggle for fair, healthy working conditions. Many factors in nursing—such as the ratios of nurses to assigned patients, the availability of medications and supplies, and the power that nurses feel they possess, stemming from what degree of organi- zation they have as a group, to contest dangerous work situations— are closely interrelated to the potential for violence at work. As the Fédération Interprofessionnelle de la Santé du Quebec (FIQ) book- let "Towards Well-Being At Work: A Policy for Fighting Against Vio- lence" describes it, "Relational suffering at work can be felt in various situations of conflict and assault and is often revealed by deterioration in labour relations. If these situations are left to deteri- orate, workplace discrimination, harassment or violence can appear. In certain cases, violence can be seen from the outset and lead directly to an escalation of violence." Since employers are providing the environment in which nurses and other healthcare workers operate, the responsibility for prevent- ing workplace violence rests squarely on their shoulders. They must dedicate planning, resources, time, and staff on an organizational level to protecting the safety of everyone on site. These changes will not come without organizing and direct action by nurses. In the United States, NNU nurses across the country have been very active in their efforts to prevent violence in the workplace, taking their fight to their state capitals, to the bargaining table, and to the streets. California nurses with NNU last year won legislation requiring the state Occupational Safety and Health Administration (OSHA) to draft regulations ensuring that all hospitals develop and implement workplace violence prevention plans. Employers are required to thoroughly assess the risk for violence in their facilities, including staffing, and implement preventive measures to protect employees and patients. Employers are also required to provide interactive training on how to recognize and respond to violence, among other topics. Finally, hospitals in California are now required to report every incident involving the use of physical force against an employ- ee directly to the state agency. The nurses' campaign included send- ing nurse delegations to state legislators' offices, and massive turnouts at legislative and regulatory hearings. Another NNU affiliate, the Minnesota Nurses Association, fought for and won prevention legislation after a particularly brutal attack on nurses by a mentally confused patient with a metal bar torn from his bed, the man from this story's opening anecdotes. The law, which went into effect Jan. 1, 2016, requires hospitals to develop action plans, pro- vide training to all staff, and to review their plans at least annually. NNU nurses in two behavioral health units at SSM Health Saint Louis University Hospital in Missouri went head-to-head with man- agement over contract language requiring the hospital to provide a safe work environment. Management had flatly denied that they M AY | J U N E 2 0 1 6 W W W . N A T I O N A L N U R S E S U N I T E D . O R G N A T I O N A L N U R S E 17 Opposite page: Irish RNs with Irish Nurses and Midwives Organisation are stepping up action for workplace safety. Above: Uruguayan nurses march for better salaries and conditions.