What you can do to keep patients & employees safe

Gregory Neal, M.D.

When Gregory Neal, M.D., covered emergency room shifts as a general surgeon, he sometimes saw trauma patients become combative. “The incidents were usually drug- or alcohol-related,” says Dr. Neal, who is now the Medical Director for Wound Care at The Surgical Center in Nashville, Tennessee, and a HealthTrust Physician Advisor. In an emergency setting, anticipating any potential violence can put a doctor, nurse or other staff member on edge, starting with the first encounter with a new patient. “There’s an anxiety level of, ‘Who am I dealing with?’ ”

The scope of the problem

Workplace violence is increasing in healthcare settings across the country, according to a 2020 Bureau of Labor Statistics report.

In the healthcare industry, the number of nonfatal occupational injuries and illnesses due to intentional actions by another person that resulted in time away from work rose from 8,180 in 2011 to 15,230 in 2018. That is almost triple the rate seen in other industries.

Workplace violence can be wide-ranging, according to The Joint Commission. It can appear as “an act or threat occurring at the workplace that can include any of the following: verbal, nonverbal, written or physical aggression; threatening, intimidating, harassing or humiliating words or actions; bullying; sabotage; sexual harassment; physical assaults; or other behaviors of concern involving staff, licensed practitioners, patients or visitors.”

The COVID-19 pandemic made it worse. A meta-analysis of studies published from 2020 through October 2022 in PMC COVID-19 Collection showed that 43% of healthcare workers experienced some violence during this period, including physical (9%), verbal (48%) and emotional (26%).

Ahmad Maarouf, M.D., MBA

“It’s certainly becoming more prevalent,” says Dr. Neal. “There are a lot of behavioral changes that have emerged as a result of the pandemic, while others are related to society and social media.”

The most common areas for hospital workplace violence are the emergency department, psychiatric units, waiting areas and long-term care or geriatric units, according to the Centers for Disease Control and Prevention (CDC). “I have seen verbal and physical abuse by behavioral health patients in the hallways of the hospital and EMS bay as they are brought in from the community,” says Ahmad Maarouf, M.D., MBA, Chief Medical Officer, HCA Houston Healthcare Kingwood, and a HealthTrust Physician Advisor.

Impact on hospital staff & patients

Workplace violence affects all types of staff members, but some are at higher risk. The PMC study showed more than double the rate of physical violence for nurses compared to physicians (13% versus 5%), while the two groups experience equal levels of verbal violence.

Abuse, no matter the type, can significantly impact clinicians, leading to their own physical and psychological trauma. It can also distract from patient care. “People can lose confidence in their job, become less engaged and start searching for exit opportunities in response to workplace violence,” explains Dr. Maarouf. A majority of emergency room physicians told the American College of Emergency Physicians (ACEP) that workplace violence impacts patients in other ways. It can cause a caregiver to pay less attention to the care plan if they are in fear of their own safety. Workplace violence can also result in workers’ compensation claims and morale issues.

Being mindful of who’s involved

While some might assume most violent encounters stem from the patient or family member directed at the healthcare worker, workplace violence can involve any combination of people.

The American Society for Healthcare Risk Management highlights examples of aggression in healthcare settings:

  • Patient-to-staff violence
  • Visitor/family-to-staff violence
  • Staff-to-staff violence/harassment
  • Physician/third-party-professional-to-staff violence/harassment
  • Stranger/nonemployee-to-staff violence

Safety is tied to better engagement & care

The first step in addressing workplace violence is recognizing it in your own workplace and seeing how it impacts your staff’s physical and mental well-being. When staff members feel safe and perceive a strong culture of safety, there is greater engagement, satisfaction and retention. Facilities ranking in the top 25% for a culture of safety have a 68% higher level of engagement compared to those in the bottom 25% for safety culture.

That engagement and culture allow caregivers to deliver better care to patients. A study in the American Journal of Nursing showed that when RNs rank their organizations in the top 25% for perceived workplace safety, the organizations experienced a 27% higher rate of job satisfaction and 22% higher overall rating from the Centers for Medicaid & Medicare Services (CMS). It also led to a 52% lower rating of patients perceiving gaps in their nurse-related care.

And it’s not just about perceptions. Organizations in that top quartile demonstrated 5% higher CMS overall hospital quality ratings versus those in the bottom quartile.

Supporting staff & protecting patients

While it may be unrealistic to think we can eliminate workplace violence altogether, hospital leadership can prepare for it, helping mitigate its occurrence and harm. Staff members should participate in hands-on training exercises and have a plan in place to support patients and staff members when workplace violence occurs.

The Joint Commission has put forth the following recommendations for hospitals:

  • Conduct annual work site analyses for workplace violence prevention programs
  • Establish processes to monitor & investigate workplace violence & other injuries
  • Train staff on workplace violence issues & maintain workplace violence prevention programs

Understanding where violence most often occurs in the hospital and providing examples of common scenarios can help leaders prepare role-playing and de-escalation educational activities. Behavioral response teams and security personnel should be trained in de-escalation and ready to rapidly deploy when needed.

Dr. Maarouf says his facility has procedures in place to help identify high-risk patients and implement measures to ensure safety. “For example, our trauma patient population is vulnerable to patient-on-patient violence. We ensure that patients who are involved in the same incident are separated, and the rounding nurse leader helps keep them under close observation,” he explains.

When workplace violence does occur, the impacted patients or staff members should receive immediate support. “The new generation of healthcare workers is more likely to report verbal abuse than the prior generation, which will help transform the culture,” Dr. Maarouf says. “This is likely due to training them to recognize workplace violence and address it through the appropriate reporting channels.”

Preparing for potential workplace violence with strategies and protocols to tackle the issue head-on is critical to a healthcare organization’s ability to fulfill its mission: quality patient care. A culture of safety is one step, as is maintaining oversight of the processes in place. “We need to encourage reporting through consistent processes to help change the culture from acceptable to zero tolerance of workplace violence,” Dr. Maarouf adds.

Hospital and health system colleagues are encouraged to contact their senators and representatives to ask them to cosponsor the “Safety from Violence for Healthcare Employees (SAVE) Act (H.R. 2584/S.2768).” This bipartisan bill would provide federal protections from workplace violence for health care workers, similar to protections in current law for airport and aircraft employees. Here’s how to message your senators and representatives about supporting the legislation.

For more information, contact your HealthTrust Account Manager.

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