Healthcare Workers at Risk
Problems, Solutions, and Priorities for Preventing Workplace Violence
The Problem of Workplace Violence in Healthcare
You’re well aware of the increasing problem of workplace violence in healthcare. A statement by OSHA reports that hospitals are one of the most dangerous places to work, and according to the 2021 IAHSS Crime Survey, hospital assaults hit an all-time high in 2020, with the assault rate increasing more than 23% from 2019.
The U.S Bureau of Labor Statistics reports that healthcare and social service workers are five times more likely to experience workplace violence than all other workers, and that their work-related injuries and illnesses comprise 73% of those across all industries.
The physical and psychological impact to victims is the clearest and most distressing consequence, with over 17% of nurses leaving their jobs every year because of workplace violence, according to a study published in the Journal of Occupational Health.
If those statistics weren’t staggering enough, organizations are facing significant consequences, as well. A study published by the American Hospital Association (AHA) estimated, “national in-facility violence costs of $428.5 million, including $234.2 million for staff turnover, $42.3 million in medical care and indemnity (compensation for lost wages made to employees who were injured on the job) for employee victims of violence, and $90.7 million in disability and absenteeism costs."
Other consequences include:
Quality of Care Suffers
OSHA reports that injury and stress in healthcare workers is tied to a higher risk of medication errors and patient infections.
Workplace Morale Decreases
When employees are emotionally fatigued, stressed, and fearful, productivity and morale decrease. Victims of workplace violence extend beyond the people who are physically injured. Witnesses can also suffer from PTSD that affects everything from their morale at work to their ability to do their jobs.
High Staff Turnover
A 2016 study by the Nursing Solutions, Inc. found that, “replacing a nurse can cost between $37,000 and $58,400.” Costs may include separation, recruiting, hiring, orientation, and training. They can also account for lost productivity while the replacement is hired and trained.
Why Workplace Violence Is a Bigger Problem than Other Industries
Although visitors and coworkers sometimes commit acts of violence in healthcare settings, patients are the source of a majority of serious violent incidents. In fact, OSHA reports that 80% of violent incidents in healthcare settings are caused by patients.
Some factors that make patients more likely to act violently include:
- History of violence: Some patients have unknown histories of violent behavior, while others arrive following disputes or gang violence and some are placed in police custody.
- Impairment: Some patients arrive under the influence of recreational drugs or alcohol, and some receive treatment with medications that can impair judgement.
- Mental illness: Irritability and anger can be symptoms of some illnesses, such as bipolar disorder and major depressive disorder.
- Brain injuries: Some brain injuries impact patient behavior, including impulse control, resulting in aggression.
- Extreme stress and fear: Often, patients are not feeling well. Add to that a difficult diagnosis and the challenging financial burden of healthcare in the US, and the stress and fear are sometimes more than a patient can handle.
Although there are ways to mitigate violent incidents stemming from these factors, healthcare organizations must provide care to patients regardless of circumstances. However, there are also environmental factors that contribute to workplace violence, and some of them are within control of the organization to address.
- Unrestricted public access: Hospitals are often open to the public around the clock, making them difficult to secure.
- Long wait times and crowds: When patients who aren’t feeling well and are desperate for care aren’t being seen, it contributes to anger and agitation.
- Presence of weapons: Most healthcare settings don’t have metal detectors or security checkpoints to prevent people from bringing in weapons, and, in some cases, items like unbolted furniture can be used as weapons.
- Lack of access to emergency communication: Not all healthcare settings have panic buttons and mobile emergency communication apps. In some settings, healthcare workers aren’t allowed to have their mobile phones with them.
- Physical environment lacking escape routes: Healthcare workers can become trapped in a room with a violent patient when there isn’t an easy escape route.
- Understaffing: Especially now, as the U.S. Bureau of Labor Statistics estimates the healthcare sector has lost nearly half a million workers since February 2020, it’s important to have enough security professionals, mental health professionals, and other clinical healthcare workers available to prevent or de-escalate violent situations.
- Lack of systems and policies in place: Healthcare facilities should have clear protocols for de-escalating situations before they become violent, warning clinicians of patients who are at high risk of acting violently, and continually improving upon protocols after each violent incident.
- Lack of appropriate training: Targeted, appropriate training is essential. De-escalation training for clinical healthcare workers should be different from workplace violence training for security professionals, and the training required for emergency department staff may be different from the training required for pediatric orthopedic staff.
- Lack of reporting: When organizations don’t have robust data about violent injuries, they can’t develop effective strategies to mitigate them.
- Culture of acceptance: Even the best protocols and training can’t prevent workplace violence if they’re not utilized. However, many healthcare workers feel violence is just part of the job – and it shouldn’t be.
For workplace violence incidents in healthcare to decrease, organizations must not only provide tools and training to mitigate it, they must also cultivate a zero-tolerance culture.
Three Top Priorities for Developing an Effective Workplace Violence Prevention Program
OSHA provides detailed recommendations for developing an effective workplace violence prevention program, and the International Association for Healthcare Security and Safety (IAHSS) also has excellent resources for members. Some organizations, like The Joint Commission, have outlined requirements for workplace violence prevention programs that must be met for accreditation.
Another excellent resource for any healthcare organization looking to build a successful workplace violence prevention program is the California Code of Regulations, Title 8, Section 3342. This is a detailed set of legal requirements for healthcare organizations in California, and it has been viewed as a model and roadmap for building a successful workplace violence prevention program.
These guidelines and requirements outline many specific steps healthcare organizations can take to mitigate workplace violence. There are engineering solutions like panic buttons, locking security doors, and enclosed nurses’ stations; personnel solutions like hiring more security professionals and social workers; and process solutions like flagging patients with a history of violence. When reviewing the many recommendations and regulations various organizations offer, three recommendations stand out.
Culture and Communication
The entire healthcare community needs to do their part to prevent workplace violence, and training is an essential empowerment tool. Everyone who works with or around patients must receive high-quality training to learn how to identify risk factors, practice de-escalation techniques, and protect themselves and exit when necessary.
The responsibility for developing workplace violence prevention programs often rests with the security team. As a result, some organizations choose a training program for the entire healthcare community that’s more appropriate only for the security team.
For a training program to be successful, it has to feel relevant to the people being trained. What’s relevant to a hospital security team is different from what’s relevant to frontline workers. That’s why the California Code of Regulations requires that frontline healthcare workers be involved in choosing, creating, reviewing, and updating workplace violence prevention training for their organizations. The only people who truly understand what frontline workers encounter every day are the frontline workers, and it’s essential they’re included when you evaluate whether a program will meet organization needs.
Once chosen, implementing a relevant training program means tailoring the program even further to the employees being trained. Ideally, trainers should include both a security professional and a clinical professional in the same field as those being trained. The particular needs of each department should also be addressed. For example, an ER physician might need a different kind of level or training than an orthopedic nurse.
All new employees should receive training before their first shift, and if your training is appropriately targeted, employees that move from one department to another should also receive new training for the new department. All employees should repeat training yearly, and those working in high-risk settings should repeat it more frequently.
Complete, efficient, and consistent reporting is the number one solution that enables all other workplace violence interventions to succeed.
You can’t know where your organization needs extra support or which intervention will be most effective if you don’t know exactly what’s happening, where it’s happening, when it’s happening, and why it’s happening. It’s also difficult to justify additional spending for security needs when you don’t have robust data to back up your requests.
Having robust data about workplace violence in your healthcare organization is essential, as shown by one study looked at the effect of a single prescribed intervention: a 45-minute walkthrough, during which unit supervisors received specific data showing the rate and severity of violence in their unit compared with the data for the rest of the organization. No particular action was prescribed, but the supervisors were shown environmental risk factors during the walkthrough along with a general list of possible workplace violence interventions based on CDC and OSHA recommendations.
The study used data from the healthcare system’s incident reports to identify which units had the highest risk of high-severity violent incidents. Half of those units served as the control group and received no information, and other half received the 45-minute. Units were tasked with putting together an action plan based on the data presented to them.
Understanding the data helped these units develop targeted action plans that kept their rate of workplace violence steady and decreased the rate of injury due to violence, while the rate of violence in the control group increased significantly over 24 months.
When you know exactly where and what the problems are, you can begin to develop an informed strategy for solving them.
What Are Some Helpful Metrics to Track?
- Rate of Violent Incidents per 100 FTEs
Knowing the rate of incidents in each unit helps you identify high-risk locations that might need more resources or an updated violence prevention plan.
- Severity of Incidents
When you have to prioritize, begin with units that have both a high rate and high severity of incidents.
- Time and Day of Occurrence
You might find you need more security presence in the ED on Friday evenings or that the most violent incidents in a certain department happen after visiting hours are over. Changing your operating protocols during those times may help prevent increased violence.
- Patient Information
Develop a method to flag patients with histories of violence so clinicians can be prepared.
- Incident Details
You may notice patterns in patient behavior that help you develop more effective prevention techniques.
- Response Details
Tracking response details helps you discover what’s working and what’s not, so you can use the data to optimize training and processes.
Did something “almost” go wrong? Recording mishaps helps you learn what caused the situation to “almost” go wrong and what you did to prevent a bigger problem.
The only way to improve your workplace violence prevention strategies is to keep meticulous records of what’s happening, what you’re doing about it, and how it’s working. It’s important to continually review the data from your reports to learn what’s working well and consider where improvements need to be made.
Culture and Communication
Reporting is the one intervention that enables all others to succeed, but without the right culture and communication strategies around workplace violence, you won’t get the data you need.
Underreporting is a significant problem in the healthcare setting. As high as the reported numbers are, actual incidents of workplace violence are likely much higher than reports show. In fact, one study reported on by the ASIS Healthcare Security Council indicates that nurses only report 50% of workplace violence incidents, and researchers at Michigan State University estimate the number of injuries caused by workplace violence in healthcare could be three times the number actually reported.
What factors lead to underreporting?
Workplace violence happens so frequently in the healthcare setting that workers view it as part of the job. When it’s perceived as normal, it’s unlikely to be reported.
Healthcare workers naturally feel empathy for their patients. They understand that sometimes patients act out because they’re feeling terrible or are impaired by their illness and medications. They don’t want to stigmatize their patients by filing a report.
Whether actual or perceived, if workers feel that filing a report wouldn’t change anything, they are less likely to report.
If reporting systems are difficult to access and use, busy healthcare workers often won’t take the time to report.
In some cases, healthcare workers fear retaliation if they report.
To overcome these obstacles and get the robust data your organization needs, it’s important to cultivate a culture of reporting.
Reporting should be encouraged, supported, and required.
Your state or accrediting body may have a clear definition of workplace violence, including reporting requirements, but you don’t have to limit your reporting to what is required. Establish a clear definition of what workplace violence is and what offenses are reportable, and make reporting a requirement. The more complete your reporting is, the better picture you’ll get of where your problems lie and what you can do to solve them.
Creating a culture of reporting requires an organizational mindset change.
Consider what kind of cultural or administrative shifts need to happen to address them.
Communicate frequently to your healthcare community that violence is not a part of the job. It’s a problem you’re committed to addressing.
Make it clear that the purpose of reporting is not to discipline or stigmatize patients who are acting out. Even offenses that may be minor, understandable, or out of the patient’s control because of cognitive impairment must be reported, since understanding why and how all violent incidents occur is the best way for your organization to develop strategies that can prevent them.
Follow up on all reports of violent incidents. Inform the victim of what your organization is doing to address the particular problem that was reported or to help prevent the type of problem from happening in the future.
Use a robust records management system (RMS) with customizable fields and mobile capabilities that make reporting fast and easy – anywhere where there’s a computer or mobile device. A good software solution will not only streamline reporting processes, but it will also include easy and customizable report-generation capabilities that help your organization analyze and respond to the state of workplace violence on a regular basis.
Make it clear that there will never be any retribution for reporting. Everyone from the C-suite on down should be involved in communicating that your organization supports a culture of reporting so that you can all work together to ensure a safe environment for all employees.
Finally, communication is key. The messages above must be communicated regularly – during daily huddles, in newsletters, on signs throughout facilities, and in training.
However, communication isn’t only about getting your message across. It’s also about listening to every stakeholder in your organization and giving everyone a place at the table. Committees that analyze the data you gather, respond to reports, and develop workplace violence intervention plans should be interdisciplinary. There should always be both clinical and security professionals at the table, and ideally behavioral health specialists should always be included. Not only will you gain a more complete perspective of the problems and possible solutions, but you’ll also create a culture where everyone feels responsible for working together to create a safer community at work.
Workplace Violence Prevention Programs May Soon be Required Everywhere
With incidents of workplace in healthcare on the rise, it’s more important than ever that healthcare organizations develop robust, effective workplace violence prevention programs.
Soon, it may even be a requirement for every healthcare organization. Right now, there are no federal laws requiring healthcare settings to implement workplace violence prevention programs, and the American Nurses Association reports that only eight states require them.
However, the tide is turning. More states are introducing legislation to address workplace violence in healthcare, and the Workplace Violence Prevention for Health Care and Social Service Workers Act (H.R. 1195) passed the House vote on April 16, 2021, indicating that there may soon be federal regulations that require employers to address the issue with specific programs and interventions.
While Congress moves slowly, the Joint Commission has already acted. Effective January 1, 2022, hospitals accredited by The Joint Commission are required to follow new and revised requirements to help prevent workplace violence.
Regular training and robust reporting are both key to all workplace violence prevention recommendations and requirements.
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