Violence Continues to Threaten Hospital Workers and Patients
By Greg Freeman
Hospitals and other healthcare facilities struggle daily with the threat of violence from patients and visitors, requiring more effort to identify potentially violent people and take steps to prevent injury.
In November 2022, CMS highlighted the growing violence in healthcare settings with recommendations that include improved staffing levels, training, and education, as well as better identification of patients who may become violent. CMS referenced a Bureau of Labor Statistics Fact Sheet from 2020 that noted healthcare workers accounted for 73% of all nonfatal workplace injuries and illnesses, a figure that has risen steadily since 2011.
“CMS will continue to enforce the regulatory expectations that patients and staff have an environment that prioritizes their safety to ensure effective delivery of healthcare,” CMS noted.1
The Joint Commission (TJC) released workplace violence prevention standards that took effect Jan. 1, 2022, along with a free webpage that includes tools to assist healthcare organizations.2
When working to prevent violence in hospitals and other healthcare settings, it is helpful to think about violence as two different types of behavior, Marisa Randazzo, PhD, executive director of threat management at Ontic, an Austin, TX-based company that provides security improvement services for businesses. Randazzo served with the U.S. Secret Service for a decade, most recently as the agency’s chief research psychologist assigned to the National Threat Assessment Center.
One type is reactive violence, such as when someone goes from disagreeing verbally to physically assaulting another person, Randazzo says. The person did not plan to be violent but lost control.
“That type of violence happens pretty frequently in our society, and it happens within hospitals, especially directed at nurses and other care providers. It’s a reactive or impulsive violence, so you have to have measures to prevent that,” Randazzo explains. “There is a lot you can do to prevent that kind of violence.”
A key measure to prevent reactive violence is training staff members in de-escalation techniques, Randazzo says. This training should be provided to nursing staff, technicians, intake personnel, receptionists, and anyone else who might be on the frontlines of interacting with patients and family members.
The other type is targeted violence. These incidents include stalking directed at healthcare providers, domestic violence that may affect the hospital, and violence intended as revenge, Randazzo says. That type of violence is highly preventable because it usually requires planning. Typically, there is a progression of detectable behavior before the violent act.
“We see that it is often carried out by someone who is angry at the hospital for something. Maybe a family member passed away and they felt there was insufficient care. Maybe they used to work there, and they were fired, and they felt like their termination was unfair,” Randazzo says. “Maybe they’ve got an estranged romantic partner who works with the hospital, and they know that that’s where they can find that person every day.”
Fortunately, hospital workers often can sense someone is headed toward violence. A co-worker might express concern about a colleague or notice that someone is posting threats on social media. An employee might divulge he or she took out a protective order against an estranged spouse. Such concerns should prompt a threat assessment investigation. If the concerns are serious enough, the next step is determining how to intervene.
“This type of violence is highly preventable because the people who carry it out usually do so when they’re at a point of personal desperation. They may even be actively suicidal, because we see a lot of the violence carried out by someone who just doesn’t care if they live or die,” Randazzo notes. “They may even be hoping to be killed by law enforcement when they provoke this type of violence. But we have a lot of tools to address someone who is suicidal, who’s despondent, or who sees violence as the only option or the best option for solving their problem.”
The interventions may include contacting local law enforcement and taking in-house actions such as alerting front desk security to the nature of the threat and the person’s identity.
Randazzo advises risk managers to determine if their facilities employ a threat assessment team or threat management team, and if not, to urge the creation. It should be multidisciplinary and called into action any time the hospital learns of troubling behavior or threats.
“The second most important question a risk manager for a hospital can ask is have they had training in threat assessment and threat management?” Randazzo says. “You want to make sure this team has had training by people who know what they are doing — threat assessment practitioners who have walked the walk, who have handled cases directly themselves, and who sat across the table from someone who’s engaged in threatening behavior and figured out an intervention plan.”
The hospital also must track violent incidents and threats, which is required by TJC. The data are important for understanding what kind of violent incidents and threats are occurring, how often, by whom, and in what areas of the facility. Without that information, the hospital cannot effectively use its resources and prevent violence.
“That is one of the areas where we’re seeing hospitals and healthcare settings just starting to get up to speed. They may have some data that are captured by individual nurses’ stations, they may have data that’s captured by human resources, or other data captured by corporate or by their hospital security,” Randazzo explains. “They don’t have a place to centralize all that, so they don’t necessarily know everywhere these things are occurring. Or they may have three different data points that actually are all talking about the same incident.”
Randazzo also recommends training for supervisors in signs to watch for among employees and how to report them to the threat assessment team. “I’ve seen hospitals be largely reactive for a long time and not have the in-house capability of a threat assessment team,” she says. “More hospitals are developing that resource, and The Joint Commission has really helped to make that prevention a clear priority for hospitals and healthcare settings so that they can prevent these incidents and not just react to them.”
Violence in healthcare takes many forms, including physical aggression and assaults, verbal threats, intimidation, harassment, bullying, sexual harassment, and assault, says Georgia Reiner, risk specialist for the Nurses Service Organization in Philadelphia.
The Bureau of Labor Statistics reported the incidence of healthcare worker injuries due to workplace violence increased 63% from 2011 to 2018, Reiner notes. Bureau data also reveal that in 2018, healthcare and social service workers were five times more likely to experience workplace violence than all other workers.3 However, workplace violence incidents are widely understood to be underreported. The American Nurses Association estimated between 20% and 60% of workplace violence incidents go unreported.4
Hospital leadership must facilitate a workplace violence prevention program that aligns with guidelines from organizations including OSHA, CMS, and TJC, Reiner says. The program should be led by designated individuals who are advised by a multidisciplinary team, including frontline clinical staff.
“Hospitals should take a zero-tolerance approach to violent, disruptive, or inappropriate behavior by staff, patients, and visitors. The program should take a supportive, nonpunitive approach that actively encourages the reporting of any concerns regarding weaknesses in the system or potential safety hazards that increase the risk of violence,” Reiner says. “Potential safety hazards that staff should be encouraged to report include inadequate staffing, lacking security responses to requests for assistance, disabled alarms, insufficient or unclear training, or perceived biases toward patient satisfaction at the expense of protecting workers’ health and well-being.”
The workplace violence prevention program must include training, education, regular drills/response exercises, and resources for hospital leadership and staff members. Hospital staff should know what constitutes workplace violence, including reportable incidents, as well as the roles and responsibilities of hospital leadership, clinical and non-clinical staff, security, and law enforcement.
“Lacking or inadequate reporting of workplace violence is one of the biggest barriers to making progress toward reducing future incidents of violence. Hospitals should identify barriers to reporting incidents of workplace violence in their facilities and work to reduce the root causes of those barriers,” Reiner says. “These barriers can be cultural, such as a perception that violent incidents are routine, not serious enough to report, or ‘just part of the job,’ or a belief that reporting an incident will lead to blame, retaliation, or even inaction on the part of the hospital. They also can be systemic, such as inadequate training or unclear instruction regarding reporting and managing workplace violence.”
All hospital staff should be trained to respond to specific threats, including how to report any threats they have witnessed, received, or were told of by another person. If an individual makes a threat and then immediately begins to follow through on that threat, hospital staff should be instructed to call law enforcement, Reiner says. If the threat is not imminent, and the individual does not seem to pose an immediate danger to themselves or others, the hospital chain of command should be followed.
“Following any kind of violent incident, hospitals should have a follow-up process to investigate incidents, identify root causes, and analyze data. Follow-up policies and procedures also should include support for victims and witnesses affected by violence, including time off from work and counseling services as necessary,” Reiner says. “Hospitals should contact their employee assistance program [EAP] following violent incidents so they can recommend appropriate counseling opportunities for affected individuals. EAPs can help the hospital facilitate on-site counseling services in the immediate response, such as by offering critical incident stress debriefings, and/or help colleagues connect with counselors on an individual basis to help process the trauma going forward.”
REFERENCES
- Centers for Medicare & Medicaid Services. Workplace violence — hospitals. Nov. 28, 2022.
- The Joint Commission. Workplace violence prevention resources.
- Bureau of Labor Statistics. Workplace violence in healthcare, 2018. April 2020.
- American Nurses Association. Reporting incidents of workplace violence. 2019.
Hospitals and other healthcare facilities struggle daily with the threat of violence from patients and visitors, requiring more effort to identify potentially violent people and take steps to prevent injury.
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