Healthcare violence now a public health issue
Moving beyond limited occupational risk view
It’s time to view violence against healthcare workers as a public health problem, not just another in a long list of occupational hazards, says the lead author of new study1 on the issue.
“Workplace violence sometimes — at least in the research world in healthcare — gets siloed,” says Lisa A. Pompeii, PhD, a former employee health professional who is now a professor and researcher in the school of public health at the University of Texas Health Sciences Center in Houston. “It’s published in an occupational journal and seen as a workplace issue — not as a public health issue. We think of violence happening in our community as public health-type violence, but when it occurs in the workplace it seems to be hidden a little bit.”
Broadening the focus would put the threat in bolder print and show that a vital part of the community is under siege.
“We need healthy healthcare workers — that’s the whole point of looking at this from a public health perspective,” she tells Hospital Employee Health. “We need these workers. They’re really important to the overall health of the public and we really need to take care of them. We need to see the workplace as part of the larger public health environment.”
DANGEROUS JOB
Do healthcare workers have the most dangerous job in the U.S. labor force? If not, they are on the short list.
“It’s a very dangerous job because there are so many occupational hazards,” Pompeii says. “They are dealing with violence, physical strain, musculoskeletal injuries, blood and body fluid exposures, respiratory hazards. It is a really demanding and a really valuable job.”
It’s hard to quantify and rank these myriad risks, though one could hazard a guess that physical injuries associated with unsafe handling and lifting of patients is certainly one of the leading occupational threats to heathcare workers. Another is the aforementioned violence from patients and visitors, both physical assaults and the implied threat that comes with verbal abuse. Fears raised by possible violent situations can certainly contribute to ongoing stress, job dissatisfaction, and anxiety. For example, about two-thirds of “sitters” assigned to watch over at-risk patients reported during threatening encounters they felt frightened or worried about their personal safety.2 (See related story, cover.) In the broader study1 of healthcare workers in general, 38% reported fear for their safety during threatening encounters with patients or visitors.
In this latter study, Pompeii and colleagues sought to estimate the prevalence, nature and consequences of type II violence (patient or visitor threat to healthcare workers). They solicited input directly from hospital workers whose jobs likely involved interacting with patients and/or visitors across six hospitals in two large health systems, in geographically distinct regions of the U.S. Eleven thousand workers were invited to participate in the survey and about half responded. The overall prevalence of respondents reporting at least one type II violent event in the prior 12 months was 39%.
Breaking down the 39%, Pompeii and colleagues reported that 2,098 of 5,385 workers surveyed reported 1,180 physical assaults, 2,260 physical threats, and 5,576 incidents of verbal abuse. Direct care providers were at significant risk. Participants in jobs typically involving direct patient care were more likely to indicate physical assault, including 30.5% (75/246) of the events experienced among nurses’ aides; 24.5% (62/253) among physical therapists/techs; and 21.5% (229/1,093) among nurses. For comparison, OSHA reports that registered nurses have more than a threefold higher risk of violent injury resulting in days lost (14 per 10,000 nurses) than U.S. private industry as a whole, which suffers 4.2 lost-day violent injuries per 10,000 full-time employees. Workers classified as “nursing assistants” have injury levels off the charts, more than tripling the rate in RNs with 55 injuries per 10,000 full-time employees, OSHA reports.3
VERBAL ABUSE
In the Pompeii study, workers in jobs that require more verbal interaction than direct care with patients and visitors were more likely to report verbal abuse. These included 61% (66/108) of events experienced by nurse managers; 78.1% (32/41) experienced by social workers/case managers; 86.7% (13/15) by pharmacists; 80.8% (21/26) by food service workers and 80.7% (152/177) by administrative staff.
Overall, 4.6% of workers were injured and 2% missed workdays. In a particularly concerning finding, the researchers noted that only 19% of the total events were reported into official reporting systems.
“People don’t report because they fear retribution, they accept it as part of the job, they don’t think management will do anything about it, or they don’t think that it is severe or serious enough,” Pompeii says. “What we found is it depends on how you define reporting. While 75% of respondents indicated they reported the incident — the majority of them didn’t report to a formal reporting system. They reported it to their manager or a coworker, but it didn’t go into formal reporting system.”
As may be the case in many other hospitals, the facilities under study had no formal requirement that a manager had to then report the injury into an official surveillance system.
“Some hospitals do have that policy, and it would probably be a good policy to have nurse managers make those reports once their employees report to them and make sure these [incidents] go into the system,” she says.
Perpetrator circumstances attributed to violent events included altered mental status, behavioral issues, pain/medication withdrawal, and dissatisfaction with care. Moreover, events of verbal abuse resulted in 30% of respondent victims feeling frightened for their personal safety — indicating that it should not be assumed that these events are not as serious as physical assaults or threats. Physical assaults more commonly involved a body part as a weapon followed by body fluids, while traditional weapons were used in less than 1% of events.
The perpetrator was a patient in 1,596 incidents and another 502 involved visitors, who were most often angry about some aspect of patient care. Visitors were involved in 18 physical assaults. “Visitor perpetrated events, which were mostly verbal in nature, centered largely on concern for the patient,” the authors reported. “Wait times and crowded waiting rooms were not as prominent as we expected based on other reports.”
What can employee health professionals do to develop a more proactive approach to the problem? Make sure the incidents are formally reported and the workers’ feel their concerns are being documented and addressed, Pompeii says.
“A lot of hospitals don’t have a workplace violence prevention policy and some don’t [require] reporting,” she says. “Reporting should be an integral part of the policy and workers should be trained on the importance of reporting and be told what employers will do with that information and why they need it. There needs to be some process to validate the workers concerns [and acknowledge] what they reported. Then they will be more likely to report in the future, so I really think that should be anchored in policy. The policy should be real specific to what systems they should report and make it very clear.”
While the threat of occupational violence could certainly undermine patient safety, the problem has not been traditionally recognized as such, but rather seen as a separate and often a lower priority issue.
“Healthcare professionals have a tendency to kind of ‘own’ some of this,” Pompeii says. “I don’t think they should be owning it, but in some of our focus groups what really came out was that the workers are conflicted. It’s their job to take care of that patient, and then they turn around and report them — it’s almost like tattling. There is some conflict there for the worker. There is more that could be done by hospitals to show concern, but there is lack of hardcore evidence right now of how it affects patient safety and the quality of care. There is anecdotal stuff, small bits of information, where nurses indicate that [violence] affects my ability to provide care, but there hasn’t been larger study done on that. That is probably the next step.”
REFERENCES
- Pompeii, LA, Schoenfisch AL, Lipscomb, HJ, et al. Physical assault, physical threat, and verbal abuse perpetrated against hospital workers by patients or visitors in six U.S. hospitals. Am J Ind Med 2015;58:1194–1204.
- Schoenfisch, AL, Pompeii, LA, Lipscomb, HJ, et al. An urgent need to understand and address the safety and well-being of hospital “sitters” Am J Ind Med 2015;58:1278–1287.
- Occupational Safety and Health Administration. Guidelines for Preventing Workplace Violence for Healthcare and Social Service Workers. U.S. Department of Labor OSHA 3148-04R 2015: http://1.usa.gov/1NlEvig.
It’s time to view violence against healthcare workers as a public health problem, not just another in a long list of occupational hazards, says the lead author of new study on the issue.
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