Healthcare workers under assault: Taking steps to address workplace violence

From violent verbal outbursts to physical assaults, healthcare workers face threats to their safety almost daily in hospitals across the U.S.

As a nurse for 32 years, I’ve been involved in my share of dangerous workplace situations — witnessing a security guard thrown against the wall to land unconscious on the floor, triaging an armed gang member in the emergency department (ED) for injuries sustained during a gang fight, being punched in the face by an intoxicated teen and numerous instances of verbal abuse. I consider myself lucky that none of the events resulted in serious injury.

These scenarios of violence have become all too common — often with serious consequences. And it’s an issue that hits healthcare workers far harder than employees in other industries. The U.S. Bureau of Labor Statistics tracks incidence rates of nonfatal occupational injuries and illnesses involving days away from work, including “intentional injury by another person.” Of the 18,400 injuries, reported in 2017, 71% were reported in the healthcare and social assistance sector.

The Occupational Health and Safety Administration (OSHA) reports that incidents of workplace violence are four times more common in healthcare settings. And the problem is getting worse, especially in EDs, where a combination of factors is at play, including increased mental health crises and substance abuse disorders and dwindling resources for high-risk people.

In recent years, healthcare workers are increasingly feeling the fallout from the opioid epidemic. A recent American College of Emergency Physicians survey revealed that half of emergency physicians said that half of all assaults are committed by people who are either seeking drugs or under the influence of drugs or alcohol.

Workplace violence isn’t “part of the job”

As alarming as the published statistics are, the reality is likely even worse, as incidents of violence and acts of aggression in healthcare settings have been found to be severely underreported, according to a 2016 New England Journal of Medicine article review. For instance, only 30% of nurses and 26% of physicians who experience workplace violence report the incidents, indicating that many healthcare workers believe that dealing with workplace violence is simply part of the job.

Efforts toward reversing this notion are underway across the country. In 2007, I was part of an Emergency Nurses Association workgroup that conducted one of the first research studies on violence against nurses working in U.S. emergency departments. The study concluded that significantly decreasing ED violence cannot occur without legislative action at the state and federal levels and innovative strategies at the hospital and department level.

Following the study, I began working with Kentucky Senator John Schickle in 2011 to raise awareness of the workplace violence epidemic in EDs. The hard work by many healthcare workers, nursing organizations, physicians, police chiefs and the Kentucky Hospital Association across the state resulted in the passage of a bill in 2012 that carried stiffer penalties for assaulting a healthcare worker or any person in an ED. This bill was unique because it covered all people within the emergency department. In 2018, I worked with Kentucky legislators again to expand the 2012 ED bill to protect the entire hospital.

Since then, many states have passed similar legislation. The first federal bill was introduced in 2018 to protect nurses and other healthcare workers from the high rates of violence they experience on the job.

For hospitals, acknowledging that there is a problem is the first step. Removing the barriers to reporting is critical. It’s also vital to have a reporting policy so that clinicians and staff feel supported by hospital leadership, management and security in reporting a violent incident. The next step is to create a violence prevention plan to increase safety, heighten awareness of violence and implement interventions to prevent it. By taking a proactive approach to tackling workplace violence in hospitals, we can create safer environments for healthcare workers and, at the same time, improve patient care.

An environment of safety

As a result of legislation mandating workplace violence prevention programs, many health systems are now taking a multipronged approach to address the epidemic. Safety rounds, environment of care rounds, huddle boards, panic buttons, metal detectors, locked perimeters, added lighting, visitor badge systems, reporting policies, police and security presence and de-escalation training are just some of the strategies hospitals have implemented to provide a safe environment for providers and patients.

Collaboration, innovation and information-sharing are important components of preventing workplace violence. When a patient with a history of violent behavior at the hospital enters the facility, a digital rounding tool like GetWell Rounds+ can immediately alert providers about the patient. EMRs and daily unit huddle meetings are also effective methods of flagging patients who are potentially violent. Knowing in advance that a patient was previously involved in a violent incident at the facility enables the hospital to increase security presence and allows providers to take safety precautions.

These strategies can also be used to prevent a violent incident from occurring. Maybe a patient hasn’t behaved violently, but a nurse simply has an uneasy feeling about the person. A digital rounding tool provides an effective way to leave a note for the next nurse who is rounding on the patient. If warranted, the care team can create a plan to head off a potentially dangerous situation with the patient. Too often as healthcare providers, we don’t listen to our instincts. When this happens and we fail to share information with our team, that’s when things can get unsafe. Remember: see something, say something. Empowering staff through support and transparency.

At my hospital, we began badging visitors who were planning to stay past 9 p.m. Using GetWell Inpatient, a system-wide banner message about hospital safety would display daily at 7 p.m. notifying patients and visitors with instructions regarding visitation after 9 p.m. They were informed that at that time visitors needed to notify their nurse so security could come to the unit and badge them.

These digital rounding and interactive patient care systems are also effective tools that can be used for more urgent communications, such as alerting patients and staff about an active shooter situation.

Zero tolerance for workplace violence

As healthcare workers, we must be advocates not only for our patients but also for ourselves. Just as patients have the right to a safe healing environment, healthcare providers are entitled to a safe work environment, one that is free from verbal or physical violence. A safe work environment is built upon trust and openness. No case should go unreported and a zero-tolerance policy toward workplace violence must be adopted to ensure we can protect ourselves and deliver safe patient care. How do we create such a culture of safety?

Create a culture of safety through collective mindfulness and a just culture

  • Staff and leaders value transparency, accountability and mutual respect
  • Safety is everyone’s first priority
  • Not accepting behaviors that undermine the culture of safety
  • A focus on “awareness” — the ability to identify/ prevent/lessen dangerous conditions at early stages before violence/mistakes/injury occurs
  • Emphasis on reporting violent situations/errors and learning from mistakes, “no blame”
  • Careful language to facilitate conversation and communicate concerns

No such thing as “just a nurse”

Often times the phrase, “just a nurse” is used by many nurses and others when referring to their inability to invoke change in healthcare. The perception that frontline nurses have no power over their environment is one that must be changed. Nurses are the face of the organization and spend the most time with patients. This perception change must come from the executive suite! Transparency of support with workplace violence is critical. Executives need to be visible and part of the solution.