Freed Associates

Reducing Violence against Your Health Care Staff

By John B. Tanner

TOPIC: Competitive Marketplace, Health Care Leadership

As seen in the AAHAM Journal.

Workplace violence against health workers is rising and gaining more attention from providers, professional organizations, the media, and regulatory bodies such as the Joint Commission, which recently published a Sentinel Event Alert on the topic. From 2002 to 2013, incidents of serious workplace violence against health care workers were four times more common in health care than in private industry, according to the Occupational Safety and Health Administration. Most violence is perpetrated by patients or visitors, according to the 2017 Healthcare Crime Survey.

What can health care providers do to stem the tide of workplace violence and ensure the safety of all? According to industry experts, the best way to improve workplace safety is defining, assessing, and tracking workplace violence while simultaneously implementing multiple solutions.

Understanding Workplace Violence

The National Institute for Occupational Safety and Health defines workplace violence as “violent acts, including physical assaults and threats of assault, directed toward persons at work or on duty.” Another important and common component includes verbal violence – e.g. harassment, verbal abuse, hostility, intimidation – which often escalates into physical violence.

In health care, some unique contributing risk factors for workplace violence include:

  • Work with patients and visitors who have a history of violence or who may be delirious or under the influence of drugs
  • A lack of violence mitigation training and policies for staff
  • Inadequate security staff
  • Long patient wait times and overcrowded waiting rooms, leading to patient frustration
  • High staff member turnover and understaffing
  • A perception by staff that violence is tolerated and reporting incidents has no effect

Potentially violent hot spots among providers include areas you would expect, like the ED/ER, psychiatric units, and geriatric long-term care settings with high populations with Alzheimer’s disease or dementia. According to the Bureau of Labor Statistics, nursing assistants experience the highest rate of violent injuries resulting in days away from work.

Workplace violence, however, can happen anywhere in the health care system and to any health care professional. Patients, who typically seek care because things are not going well, may be experiencing pain, dealing with a devastating prognosis, navigating unfamiliar surroundings and/or taking mind/mood-altering medications. Patients may also experience psychosocial components such as poverty, stigmatization or lack of social support. These stressors can increase patient conflict and the risk of violence.

Challenges of Addressing the Issue

Under-reporting of workplace violence in health care, especially bullying and verbal abuse, is common. A Minnesota survey of nurses found only 69 percent of physical assaults and 71 percent of non-physical assaults were reported to a manager. Reasons for not reporting include lacking a reporting policy and/or fearing retaliation. Moreover, there are cultural factors such as health care professionals feeling an ethical duty to “do no harm” to patients or accepting violence as part of the job. Professionals acknowledge many patients unintentionally cause staff injuries due to stress, disorientation or medication side-effects.

Workplace violence in health care leads to significant provider costs. A report from the American Hospital Association estimated that workplace violence cost U.S. hospital and health systems approximately $2.7 billion in 2016. Direct costs include ongoing security and staff training, establishing preparedness and prevention measures, and compensating victims for medical treatment and missed days of work. Indirect costs include staff burnout and turnover.

What Can Be Done?

There are currently no specific national laws addressing workplace violence in health care. Some states have enacted their own regulations to criminalize violence against health professionals. Alaska, Hawaii, New York, and Utah now have harsh penalties, including prosecuting incidents as felonies. In October 2016, California passed the toughest rules in the country requiring health care employers to develop tailored violence prevention plans from employee input; full implementation of the California regulations went into effect April 1, 2018.

What should you be doing in your health care facility? In addition to the Joint Commission’s seven recommended actions to combat workplace violence, consider these 10 specific violence mitigation tactics:

  1. Educate staff on ways to address agitated or aggressive behavior early before it escalates.
  2. Encourage conversations about workplace violence during daily huddles.
  3. Perform a risk assessment (potentially with external help) with input from multiple hospital databases (e.g. security, HR, complaints, legal/risk), discussions/surveys with employees, collaboration with similar organizations, and implement changes based on the assessment.
  4. Evaluate environmental design changes such as: installing barriers, removing objects which could be used as weapons, installing bullet-proof glass and metal detectors, using color, lights, and decorations to create a more peaceful environment, creating larger waiting areas to avoid overcrowding and using closed-circuit TV to demotivate criminal or unsocial behavior.
  5. Develop checklists or questionnaires for staff members to help determine if a patient is irritable, threatening, or confused.
  6. Keep internal and external public-facing premises, including parking facilities, elevators, stairways and restrooms, clean and well-maintained; in criminology, a well-cared-for space is known as a factor to reduce aggressive or criminal acts.
  7. Encourage communication with patients especially around wait times and delays to avoid irritation and impatience.
  8. Ensure the EHR contains sufficient and up-to-date information about any past issues of violence with the patient.
  9. Create special emergency codes and multidisciplinary response teams to deal with potential violent situations and provide alarm options such as: stationary or mobile alarms; panic buttons; audible or visual alarms.
  10. Avoid having staff members work alone or in isolated environments as much as possible.

The more violence mitigation tactics which you implement in your health care organization, the greater the likelihood of significantly reducing the likelihood of workplace violence. Your staff members, patients and visitors are counting on you for their safety and well-being.

John Tanner is a consultant with Freed Associates, a California-based health care management consulting firm.