Editor’s Note: This issue was originally published in the 2016 Spring Issue of Alabama Medicine magazine.
Going postal, unfortunately, is part of our pop-culture lexicon. This well-known phrase indicates the workplace isn’t as safe as we once thought.
Hospitals and health care facilities were once considered safe havens from violent incidents. Unfortunately, the health care industry is more likely to experience workplace violence than most realize.
Data from the U.S. Bureau of Labor Statistics indicates in 2010 health care and social assistance workers were the victims of 11,370 assaults, more than a 13 percent increase since the year before. This shows more than a 13 percent increase since. In 2011, Modern Healthcare reported the Bureau’s statistics showed the chance of registered nurses being assaulted at work are more than triple that of the average American worker. Nurses had a 6.1 in 10,000 chance, while the general population had a one in 10,000 chance. The article further pointed out registered nurses are at greater risk of workplace violence than taxi-cab drivers or bartenders.1
The increase in workplace health care violence may be attributed to:
- deinstitutionalization of psychiatric patients;
- increased substance abuse (both street drugs and controlled substances);
- gang violence;
- economic stress;
- frustration due to long waits in emergency departments; and
- increased use of emergency departments by police to hold unruly/intoxicated patients.
Defining “Workplace Violence” and Taking Action
The National Institute for Occupational Safety and Health (NIOSH), defines workplace violence as “violent acts, including physical assaults and threats of assaults, directed toward persons at work or on duty.” 2Once violence is defined, the next step is to develop a workplace violence prevention program. The American Society for Industrial Security (ASIS) Health Care Security Council’s 2011 white paper, “Managing Disruptive Behavior and Workplace Violence in Health Care,” recommends workplace violence prevention teams adopt a multidisciplinary approach. This approach includes security, first responders, clinical staff, risk management, legal, human resources, administration, and other key stakeholders. Security experts recommend IT and security staff coordinate efforts due to increased use of technology in hospital security.
Once violence is defined, the next step is to develop a workplace violence prevention program. The American Society for Industrial Security (ASIS) Health Care Security Council’s 2011 white paper, “Managing Disruptive Behavior and Workplace Violence in Health Care,” recommends workplace violence prevention teams adopt a multidisciplinary approach. This approach includes security, first responders, clinical staff, risk management, legal, human resources, administration, and other key stakeholders. Security experts recommend IT and security staff coordinate efforts due to increased use of technology in hospital security.
The white paper also cites the International Association for Health Care Safety & Security’s five components of an effective workplace violence prevention program, which include:
- management commitment and employee involvement,
- worksite analysis (including evaluating the physical environment),
- hazard reduction and response,
- training, and
- recordkeeping and program evaluation (measured by empirical data). The white paper includes a sample threat assessment checklist, a workplace violence prevention policy, a list of common warning signs, and an assessment outline.3
The Joint Commission requires accredited hospitals assess their risk of violence, develop written plans, and implement security measures.4
Risks may vary by facility and by department, underscoring the importance of individualized analysis.
Multiple sources suggest researching crime statistics in your facility’s immediate area. A physical environment assessment may include monitoring of facility entrances, parking ramps, and grounds. A walk-through also may determine whether in-house emergency call numbers are posted and that panic buttons are available at registration desks and nursing stations.
Additionally, determine if staff lounges are locked and layouts of patient rooms help prevent entrapment. Some facilities ensure bulletproof vests are readily available.
Identify additional risks by conducting surveys with all shifts and in multiple situations. This allows you to determine whether employees are familiar with the facility’s violence prevention program and their reporting responsibilities.
A number of federal and state agencies provide easy access to information and tools to assist in conducting assessments. The Occupational Safety and Health Administration’s (OSHA) “Guidelines for Preventing Workplace Violence for Health Care and Social Service Workers” lists specific steps to access, monitor, and analyze violent events and to evaluate the effectiveness of your workplace violence program. The Guidelines also list engineering and administrative controls to help minimize violence. The guidelines, sample checklists and violence incident report forms are available on OSHA’s website, www.osha.gov.
Hazard Reduction and Response
The next step is developing strategies and policies for preventing and managing the potential for violence. Consider implementing and/or revising:
- education for administration and staff on recognizing the risk of violence;
- definitions for “violence” and certain crimes;
- an easily accessible reporting and documentation system;
- written policies and procedures and personnel responsibilities, including reporting of incidents (describe specific codes to call, who to notify in specific situations, and interactions with law enforcement);
- the facility’s assistance to employees following a violent incident;
- debriefings (within 24-72 hours of an incident); and
- ongoing training programs with required staff attendance.
Additional security measures might include metal detectors, bag searches, cameras, appropriate lighting, video monitoring, security personnel,
stationing security in high-risk locations, and nighttime escorts to parking lots.
Staff training may be one of your most effective tools in reducing violent incidents. New employees should receive violence prevention training as part of their orientation. Training should be ongoing and include supervisors and security staff. Topics may include:recognizing potentially violent situations and using de-escalation techniques;
- recognizing potentially violent situations and using de-escalation techniques;behaviors that help diffuse anger – a calm and caring attitude, avoiding giving orders, and acknowledging the individual’s feelings; avoiding behavior that might be interpreted as aggressive (rapid movement, speaking loudly, or getting too close);
- behaviors that help diffuse anger – a calm and caring attitude, avoiding giving orders, and acknowledging the individual’s feelings; avoiding behavior that might be interpreted as aggressive (rapid movement, speaking loudly, or getting too close);
- taking patients to safe and quiet areas to calm emotions; and
- move disruptive patients away from the rest of the hospital population.
Record Keeping and Program Evaluation
Lastly, it is key to document your violence prevention efforts whether to defend an employee’s or the hospital’s actions, or in response to an OSHA investigation. Thorough documentation also will assist in evaluating the effectiveness of your violence prevention program.
When Violence Occurs
Additional training may be necessary for employees in high-risk areas which typically includes emergency departments, ICUs, behavioral health, and operating rooms. Training may include proper use of restraints, physical techniques to subdue violent individuals, and administering medical care once the individual is subdued.
The Emergency Nurses Association’s November 2011 Emergency Department Violence Surveillance Study indicated the overall frequency of physical violence and verbal abuse for an ED nurse working 36.9 hours in a seven-day period was 54 percent of the 7,169 nurses participating in the study. Nurses were most often involved in triaging a patient, performing an invasive procedure, or restraining/subduing a patient when the violence occurred. Patients were the main perpetrators in all incidents; over 83 percent of the incidents occurred in patients’ rooms.
Further, the study indicates that physical violence rates increase as population density increases (9.1 percent rural vs. 14.1 percent large urban areas). The odds of physical violence occurring were higher for younger nurses; male nurses were more likely to experience physical violence than females. Also, the use of panic buttons/silent alarms correlated with less physical violence. And decreased odds for physical violence and verbal abuse were associated with enclosed nursing stations, locked or coded ED entries, security signs, and well-lit areas.5
Risk management experts recommend the following should a health care workplace violence incident occur:avoid confrontation – retreat to a safe place if possible;
- avoid confrontation – retreat to a safe place if possible;
- do not approach or attempt to disarm an individual with a weapon;
- summon security or a behavioral response team, or call 911;
- remain calm – refrain from agitating or threatening a violent person;
- isolate the individual – protect patients, lock doors, direct traffic away from the area, and evacuate if possible.
Dealing with Media and Law Enforcement
ProAssurance Risk Resource Consultants suggest hospitals develop policies and procedures for communicating with the media and law enforcement. We also suggest designating a hospital spokesperson and making sure that staff receives ongoing training for these situations.
Ensure staff knows how to respond to requests for interviews, subpoenas, and/or search warrants. Be sure to provide contact information and back-up numbers so staff knows whom to contact in such situations. Staff also should be trained on how to preserve and maintain a chain of evidence, which may include illegal firearms or drugs and statements of witnesses and victims. Lastly, ensure staff understands HIPAA privacy issues in these situations.
Of Course, Document
Once the situation diffuses, staff should document what was seen, heard, and / or done. Documentation will be critical should the facility or an employee be named in a professional liability lawsuit.
Unfortunately, violence occurs all too often in health care, but it still catches health care staff off-guard because it’s so unpredictable. Implementing and adhering to a workplace violence program will assist you and your facility in preparing for these situations and help prevent injury to you, your staff, your patients, and patients’ families.
- U.S. Bureau of Labor Statistics: https://www.osha.gov/SLTC/healthcarefacilities/violence.html\
- National Institute for Occupational Safety and Health: http://nursingworld.org/workplaceviolence
- The Joint Commission, Division of Health Care Improvement, Advisory on Safety & Quality Issues: http://www.jointcommission.org/assets/1/23/quick_safety_issue_five_aug_2014_final.pdf
- Emergency Nurses Association, Institute for Emergency Nursing Research, Emergency Department Violence Surveillance Study: https://www.ena.org/practice-research/research/Documents/ENAEDVSReportNovember2011.pdf
ProAssurance-insured physicians and their practice managers may contact Risk Resource for prompt answers to liability questions by calling (205) 877-5015 or email at firstname.lastname@example.org. ProAssurance is an official Platinum Partner with the Medical Association.