Illustration by Sarah Ferone
Illustration by Sarah Ferone.

Hospitals fight back against violence

Hospitals and clinicians are increasingly recognizing workplace violence in the hospital as a problem and employing strategies to deal with it, or better yet, stop it before it happens.

Workplace violence occurs so often in the hospital that some health care workers consider it part of the job.

Gordon Lee Gillespie, PhD, DNP, RN, estimates that he was assaulted at least 100 times in his first five or six years working as a nurse in the ED. “I wasn't watching those cues that a person's starting to escalate, so I had myself in risky situations,” he said. “And because I was the only male nurse in the ED and the only male nurse in the building for a while, any patient that was aggressive became my patient automatically.”

But dealing with violence should never be considered normal, said Dr. Gillespie, associate professor at the University of Cincinnati College of Nursing. “I personally had the belief when I started practicing that it was,” he said. “The challenge is that in health care, people look at it and say, ‘Well, it's not really their fault,’ but the behavior is always inexcusable.”

From 2002 to 2013, incidents of serious workplace violence were four times more common in health care settings than in private industry, according to the Occupational Safety and Health Administration (OSHA).

“The general incivility and violence in our society has just spilled over into all of our settings,” said Mary Beth Kingston, RN, MSN, executive vice president and chief nursing officer of Aurora Health Care in Milwaukee. Her health system's policy has encouraged a safe environment for caregivers since the ‘90s, but the language was strengthened two years ago to focus on a “no-tolerance” approach to violence in the hospital, she said. “People were like, ‘Finally, someone's on top of this,’” Ms. Kingston said.

Hospitals have commonly offered employee training and education about workplace violence risk factors and scenarios, but more of them are now going beyond the basics to tackle the problem. New approaches to preventing and mitigating violent incidents include unit-specific interventions and using the electronic health record (EHR) to follow patients involved in prior disruptive incidents.

Hospital hotspots

Within health care, hospitals are particular hotspots for workplace violence. In 2015, medical and surgical hospitals, nursing and residential care facilities, and ambulatory health care settings were among the industries with the highest prevalence of nonfatal occupational violence, with respective incidence rates of 6.0, 6.8, and 2.4 per 100 full-time workers, according to the U.S. Bureau of Labor Statistics.

These figures only represent the number of reported cases, and health care workers often do not report incidents of workplace violence, which include verbal threats, harassment, and intimidation in addition to physical assaults, said Ms. Kingston. “If someone's not physically hurt, I think that in the past, they haven't had that recognition that this still has an impact on you,” she said.

Among victims of workplace violence in health care settings, just 30% of nurses and 26% of physicians go on to report the incident, according to a 2016 review article in the New England Journal of Medicine (NEJM).

The vast majority of hospital violence is perpetrated by patients or their visitors, as opposed to staff or outsiders, according to the 2017 Healthcare Crime Survey, produced by the International Association for Healthcare Security and Safety Foundation. The most common characteristic among those who initiate violence in the hospital is altered mental status, associated with dementia, delirium, substance intoxication, or decompensated mental illness, according to the NEJM article.

No health care worker is immune to violence in the hospital, but nurses are at particularly high risk, as are ED and psychiatric ward staff. In a national survey of 263 emergency medicine residents and attendings, researchers found that 78% of participants experienced at least one act of workplace violence in the last 12 months, with 75% reporting verbal threats and 21% reporting physical assaults, according to results published in 2011 by the Journal of Emergency Medicine.

Among participants in the Minnesota Nurses' Study, the yearly incidence of verbal and physical assaults was 39% and 13%, respectively, according to a 2004 study published in Occupational and Environmental Medicine. Yet only 27% perceived violence to be a problem at work.

These days, however, nurses are becoming more aware of what constitutes violence, Dr. Gillespie said, giving the example of an elderly woman who gets confused and slaps someone. “There's no intention. But it's not the intent that denotes violence; it's the actual behavior,” he said. “I think as people become more savvy on what the definition is, then the perception is going up.”

Beyond the human toll, workplace violence in the hospital is financially costly. Hospitals spent an estimated $1.1 billion in security and training costs to prevent violence within their facilities, plus $429 million in medical care, staffing, indemnity, and other costs resulting from violence against hospital workers, according to a 2017 report commissioned by the American Hospital Association.

Prevention interventions

Health systems are clearly interested in reducing the risk of workplace violence, but very few interventions have been shown to be effective in a robust and replicable way, said Judy Arnetz, PhD, MPH, PT, professor and associate chair for research in the department of family medicine at Michigan State University in East Lansing. In 2017, she and her group published what may be the first randomized, large-scale intervention study on the issue in the Journal of Occupational and Environmental Medicine.

The two-year study included 41 units across six hospitals that had been identified as having increased risk for workplace violence. After researchers measured rates of violence and examined risk factors, they presented supervisors of 21 intervention units with three years of workplace violence data succinctly summarized in graph form.

The identified risk factors aligned with those Dr. Arnetz and her research team published in 2015 in the Journal of Advanced Nursing, such as cognitive impairment, patient pain or discomfort, physical transfers of patients, and the presence of needles. “Many times, even the patients who show the least tendency towards violence reacted with violence when a needle came into the picture, either because a nurse was setting an IV or someone needed an injection of some kind,” she said. “So it's important to recognize the risk factors so that people can be prepared.”

After learning about their units' data, supervisors received an OSHA checklist of possible prevention strategies, adapted to the hospital environment, and were instructed to work with their units to come up with an action plan.

After two years, the risk of violence-related injury was significantly lower on intervention units compared to controls (2.81 vs. 8.09 injuries each year per 100 full-time equivalents). The risk of violent events after two years was also lower on intervention units compared to controls, but not significantly so (13.77 vs. 15.41 events each year per 100 full-time equivalents).

Each intervention unit addressed its own identified problems. At one unit, for example, violence tended to occur in the evening when patient visitors were present—often between patients and their visitors—so staff began to enforce visiting hours more strictly and supplied lockers where patients could safeguard their personal belongings, Dr. Arnetz said. “These were really simple interventions, but they wouldn't have come up with the idea if they hadn't looked at their data,” she said.

Other health systems have taken more broad-based approaches. At the University of Iowa Hospitals and Clinics, the Disruptive Patient and Visitors Program has been in place for four years. As part of the program, patients and visitors who repeatedly cause disturbances or commit egregious acts of violence are flagged in the EHR. Alerts are accompanied by tips from previous caregivers on how to reduce risk, such as entering the room slowly.

Patients are informed of the alert, both in person and in written follow-up, and they are also able to appeal if they believe there's a misunderstanding, explained Lance Clemsen, LISW, a social work specialist in the ED and co-chair of the program. “We're going with the notion that silence really takes it from bad to worse,” he said. “If things can be open and openly discussed without any kind of shame [or] judgment, the outcome is almost always better.”

Administrators of the disruption program initially flag patients, with review by a multidisciplinary committee. Once a patient goes from temporary to full-time status as a disruptive patient, he or she is monitored for two years, after which the committee decides if action is still indicated or if the active alert should be withdrawn. About 60% to 70% of alerts are withdrawn after this two-year period, Mr. Clemsen said.

The program currently follows about 65 patients, or substantially less than 1% of the hospital's inpatient volume. Those patients had more than 1,600 appointments after their alerts were entered into the record, said Doug Vance, interim director of security for the hospital and a committee member for the program. “So it's not like it's really interfering with their care at all, and in many cases, it really streamlines it,” he said.

Over a two-year period, about 65% to 70% of disruptive patients had no subsequent need for heavy security involvement, Mr. Vance noted.

At Aurora Health Care, a similar pilot project allows any clinician to document violent behavior in a patient's chart. “Then, when anyone opens the chart, once a day, an alert pops up to say this particular patient has had an episode of aggression or violence, and it gives some helpful hints,” Ms. Kingston said, adding that the alerts are reviewed for applicability through a review process.

As part of the pilot, a “safety first” notice is placed on the doors of patients with alerts for broader protection. “For example, someone from food services delivering a tray would not be going into the electronic health record, and we want them to be aware or to check with the nurse before they enter the room,” Ms. Kingston said.

One concern that some clinicians have with such interventions is the labeling of patients. “One of our psychiatrists was really down on this whole process. She said, ‘You're giving them a scarlet letter. You're going to make it worse for them,’ and that just has not been the case at all,” said Mr. Vance. “She's actually now a member of our committee.”

Dr. Arnetz, the Michigan researcher, said that there have been mixed results in the scientific literature on flagging charts. “I know there was a big study at the VA system several years ago, and they found that flagging charts actually helped to reduce violent events, whereas in another study from Canada, flagging charts did not seem to help at all,” she said.

Another issue is that violence is often unpredictable. Knowing that a patient has the potential for violence may be useful, “but our studies have actually shown that you can't always predict who that person will be,” said Terry Kowalenko, MD, chair of emergency medicine at Oakland University William Beaumont School of Medicine in Rochester, Mich.

One study, published in 2013 by the American Journal of Emergency Medicine, surveyed 213 ED health care workers at six hospitals about the number and type of violent events that occurred over the course of nine months. Two-thirds of verbal threats were by men, which wasn't surprising, but there was a nearly 50-50 split between men and women when it came to physical assaults, said Dr. Kowalenko. “That is not what we expected to see,” he said.

Another challenge is determining who has authority to do the flagging, Dr. Gillespie said. “To me, the person that should not do a flag is anyone who's in a direct line of care” because of the potential for bias, he said. Instead, he encourages hospitals to have social workers or higher-level directors make the judgment call.

Mr. Clemsen noted that patients who are flagged as disruptive are never denied care by his hospital. “We are not able, by our policies, to terminate or to fire patients,” he said. Flagging charts is more about setting clear expectations for the treatment team in order to more safely care for that patient the next time, he added.

Under the Emergency Medical Treatment and Labor Act, EDs can't legally prevent a patient from coming in, Dr. Gillespie noted. “But from an inpatient perspective, you don't have that legal mandate to provide that care,” he said. “If you're on the inpatient side and people are overly acting out and it's hindering care, there are some hospitals that have told patients that they are banned.”

Individual strategies

Individual clinicians can also do their part to curtail violence in the hospital. Because ED clinicians often have an elevated tolerance of violent actions, Dr. Kowalenko said he has suggested that they pretend to be working in a different setting. “If you were a waitress at a restaurant and somebody came up to you and shoved you and called you x, y, and z, would that person still be a patron at that restaurant at that time?” he said. “I guarantee you they're either thrown out, or the police are called and they're arrested.”

In terms of self-defense, the proper response is completely different for a health care worker than a person in public, said Dr. Kowalenko, a trained martial artist who has taught self-defense courses for both groups.

“For the general public, I teach a technique that would eliminate the threat and give you time to get away. Some of those are potentially lethal: hitting somebody in the trachea, gouging out an eye. . . . In the ED, you don't have a fight with a patient,” he said. “You don't punch them in the face, even though they're trying to punch you in the face. When it gets to that point, you're trying to disarm them.”

A way to proactively disarm patients is to keep potential weapons out of their hands, said Dr. Kowalenko, offering the example of IV poles on wheels. “In most departments now, they're a part of the bed that you can't remove, and one of the reasons is because those were used as weapons,” he said.

Some other strategies to de-escalate aggressive patients are the same ones that increase patient satisfaction, such as controlling pain, responding to needs, and answering call lights, Dr. Gillespie said. “But a lot of that is really more nursing-centric and not as much for physicians and persons with prescriptive authority,” he said.

Physicians can make an effort to learn about and resolve any potential issues by talking to nursing staff during regular rounds, said Dr. Gillespie. “When patients have a need, they won't always tell the physician,” he said.

Doctors sometimes don't realize that, in most cases, they're seeing the best of the patient, said Daniel Gugala, JD, executive vice president and general counsel at the Crisis Prevention Institute in Milwaukee. “A lot of times, from a behavioral standpoint, it's the nurses who get the brunt of the challenging behavior,” he said.

Mr. Gugala recommended that physicians provide patients with cues that can help nurses later. For example, if ordering a blood test, explain to the patient that someone else will come in to take blood and will be in close proximity. “It may be that person's first experience [with health care] in years,” he said. “Clear communication and setting expectations, as far as what it is that you're going to do, can help to alleviate a lot of stress in people.”

Ms. Kingston said that hospitalists can also help discern the root cause of someone's aggression, which could be a medical condition causing hypoglycemia, for example. “If something does happen, where I see hospitalists really playing a huge role is in helping the team identify if there are any issues that may have contributed to that,” she said.

Physicians may also be called upon to perform a medical exam after a violent episode, which can not only resolve the medical cause but also help avoid inappropriate labeling of a patient as disruptive. “That's why we think this physical evaluation is so important because if there's some other reason [for the violence], we would remove that and say that was a one-time incident,” Ms. Kingston said.

If a patient is deemed to be aggressive or potentially violent, interdisciplinary communication is important to make sure that everyone at risk is aware. “Nurses may know that, ‘Oh, room 305, go in slow.’ Physicians may not know that going in,” Dr. Gillespie said.

While in nursing school 20 years ago, he said he was taught to discuss patients' clinical care, but not social issues, in order to avoid biasing the next caregiver. “But in today's world, that's the information you need to share,” Dr. Gillespie said. “Even if you don't document it in the medical record, you need to at least have the conversation because it's about safety of everyone. Creating a culture of safety requires these ‘gut[-feeling]’ discussions.”

An example of information a caregiver may pass along but not document would be a patient's husband showing signs of aggression, such as continuously pacing in the room, staring at the caregiver, and mumbling under his breath, said Dr. Gillespie. “These types of observations are not about the patient, so wouldn't go into the patient's health record,” he said. “But the team definitely needs to know about the potential for risk.”

Managing violence in the hospital is a dual responsibility between medicine and nursing, according to Dr. Gillespie. “If those two were working truly as an interprofessional team, both groups can actually be safe while also protecting the rights, dignity, and safety of our patients that are escalating toward violence,” he said.