By Don Sadler
Most nurses and healthcare workers enter the field because they want to reduce patient suffering and help patients heal. So, it’s ironic that nurses themselves can sometimes be the ones who need protection from harm.
Healthcare workers are five times more likely to experience violence in the workplace than employees in other industries, according to the U.S. Bureau of Labor Statistics. Four out of five nurses say they have experienced at least one incident of workplace violence, which costs healthcare organizations an average of $330,000 annually.
These numbers could be considerably higher since workplace violence incidents are typically underreported.
“The way that some patients now treat healthcare workers has greatly shifted since I first became a nurse,” says Lindsey M. Downing, MSN, RN, NE-BC, a nurse manager with Middlesex Health in Middletown, Connecticut. “There used to be a fairly uniform sense of respect, but somewhere along the line, it became the new norm for patients to both verbally and physically assault those providing them with care.”
Downing stresses that it’s a very small minority of patients and family members who resort to violence against healthcare workers. “Most people are grateful for the care they receive,” she says. “But those few have really changed the climate of healthcare.”
Middlesex Health Chief Nurse Executive Nancy LaMonica, MSN, MHA, RN, PCCN, NEA-BC, concurs.
“Violence levels are extremely high in acute care, behavioral health, long-term care and home health,” she says. “As nurses, we experience incidences every day in these environments.”
Violence Escalated During the Pandemic
While violence against healthcare workers isn’t new, the problem escalated during the COVID-19 pandemic when many people formed negative opinions about healthcare workers because of suspicions about mask mandates and vaccines, among other things.
“We have seen a substantial increase in workplace violence since the COVID-19 pandemic, although violence in healthcare has been documented for decades,” says J.D. Buchert, MSN(s), M.Ed., MS, RN, CNOR, workforce safety manager at Parkland Health in Dallas, Texas. “Violent episodes previously concealed within the walls of healthcare have now been catapulted into national media outlets.”
Karen Garvey, MPA/HCA, BSN, RN, DFASHRM, CPHRM, CPPS, is the vice president of safety and clinical risk management at Parkland Health and Chair of the Workplace Violence Committee. She and Buchert have been active in helping get state and federal workplace violence legislation passed.
“J.D. and I have both witnessed many workplace violence incidences in our careers,” says Garvey. “Early in our careers, we were taught that workplace violence is just ‘part of the job’ and we were supposed to accept it. Fortunately, this is no longer what’s taught or expected.”
Garvey and Buchert say that they have witnessed many different types of violence in the healthcare environment over the years: physical and verbal assault with racial or sexual disparages, destruction of property and equipment, and disruption of the healthcare environment to the point where patient care cannot be given.
“We have seen broken bones, concussions, hostage situations with guns, and even death,” says Buchert. “We’ve also seen fellow healthcare workers suffer permanent neurological and physical damage that ended their careers.”
Pat Thornton, RN, MS, CNOR, the surgical director at the Dermatology Institute in Newnan, Georgia, notes that in acute care facilities and the perioperative setting, violence from patients and family members is minimal due to strict security of entry (e.g., passkey electric doors).
“But the same security resources aren’t available at ASCs and freestanding surgery centers,” says Thornton. “The staff are constantly on guard watching for people entering the restricted area and having to manage unwelcome visitors.”
Effects of Violence on Healthcare Workers
Incidences of workplace violence can have devastating effects on healthcare workers.
“Repeated aggression toward healthcare workers can carry quite a large psychological burden,” says Buchert. “Many healthcare workers are displaying signs and symptoms of PTSD, which can lead to long-term consequences such as depression, increased absenteeism, lack of engagement, burnout or even thoughts of suicide.”
LaMonica says that the psychological effects of workplace violence are leading some healthcare workers to leave the profession. “No one pursues a career in healthcare just to be abused,” she says.
Downing concurs.
“We have seen first-hand many nurses who have either left acute care facilities or needed extended periods away to cope with the violence they experienced,” Downing says. “The physical effects of violence often fade with time, but the psychological effects may never go away.”
Thornton says that workplace violence can create “pure fear” among healthcare workers who are subjected to it.
“I have known coworkers who were afraid to walk to their car or afraid they would be followed home by angry patients or family,” she says.
Violence by patients and family members against healthcare workers may stem from a number of different factors. These include stress, mental illness, drug or alcohol use, long wait times, feeling ignored, poor healthcare outcomes, and frustration due to a perceived lack of responsiveness to their concerns.
“There are so many contributing factors associated with workplace violence, but the important question should be, ‘What can we do to help prevent workplace violence?’” says Garvey. “I believe it starts with being open and honest with patients and visitors.”
“For example, if a patient has been waiting for an appointment for three hours, are we rounding and addressing the patient to explain why they have to wait so long? Patients feeling they are being ignored or disrespected is one of the biggest contributors to escalated verbal aggression.”
If a patient’s behavior begins to escalate, Buchert recommends fast action to set behavioral expectations that will aide in creating a safer environment. “When patients start to raise their voice, we must respond without emotion and explain that we will work with them in a respectful manner, just as we expect from them,” he says.
Role of Workplace Violence Committees
Middlesex Health has formed a workplace violence committee to help reduce violence. The committee, which is chaired by nursing and security personnel, reviews all incidences of violence at the facility and identifies areas for improvement in security procedures. “This is a dynamic group that can speak to workplace violence first-hand,” says LaMonica.
“Workplace violence committees are a step in the right direction, but it’s what we do with the data tracked that will make a difference,” says Downing. “It can’t just be about the numbers or whether we’re above or below a certain benchmark.”
Parkland Health has created a peer support group called SPARKS (Supporting Parkland Staff) to provide psychological first aid to help staff impacted by workplace violence “get back to an equilibrium,” says Garvey.
“SPARKS is a three-tiered program that includes trauma counselors, a trauma psychologist and professional support as needed,” says Garvey. “This confidential program has proven to be hugely successful in supporting staff members who have been victims of or witnessed workplace violence.”
Buchert encourages hospitals and health systems to make staff safety a strategic priority by dedicating resources to preventing workplace violence. This includes creating a workplace violence prevention plan that’s reviewed and endorsed by executive leadership and the board of directors. “It’s important to have dedicated teams with a 100 percent focus on the strategic plan,” he says.
Legislation Targets Workplace Violence in Healthcare
Buchert and Garvey were instrumental in helping get legislation passed in Texas that addresses the problem of workplace violence in healthcare. “Senate Bill 240 outlines a blueprint and mandate for healthcare organizations to create safer environments for their workforce,” says Garvey. The legislation requires all healthcare organizations in Texas to form a workplace violence committee that includes a practicing physician, practicing nurse and someone who provides security services.
In addition, healthcare facilities must devise a workplace violence plan with input from employees. The plan must include workplace violence policies such as the implementation of evidence-based practices, training for direct caregivers and a reporting system for responding to both low- and high-harm events.
According to Buchert, Parkland Health was called out as the only health system in the state to have all the elements of the legislation in place before the law was signed by the governor. “This law provides the necessary support for the protection and well-being of the healthcare workforce,” he says.
Another law, Senate Bill 840, increases penalties for workplace violence against healthcare workers from a misdemeanor to a Class C Felony. “This has left many healthcare workers happy that our legislators are focusing on their safety,” says Buchert.
Meanwhile, Downing and LaMonica were actively involved in getting workplace violence legislation passed in Connecticut – HB 6741: An Act Improving the Safety of Healthcare Providers and Patients. The legislation requires the Department of Public Health to develop a marketing campaign and make monthly public service announcements discouraging aggressive or violent behavior against healthcare workers.
When announcing the legislation, Senator Henri Martin said he wasn’t aware of the severity of the problem until he met with LaMonica and 20 other nurses, doctors and healthcare security personnel.
“That’s when I learned that hospitals were not so safe places,” Senator Marin said. “In recent years there has been a spike in verbal and physical attacks on hospital staff. This abuse needs to stop – there should be zero tolerance for any type of hostility toward healthcare workers.”
Downing says she enjoyed visiting the state capitol and learning the ins and outs of how legislation is passed. “We had unanimous support from our state representatives, which was really great to see,” she says.
In addition to state legislation, The Joint Commission has begun enforcing workplace violence prevention standards applicable to all accredited facilities. These include conducting an annual worksite analysis related to the facility’s workplace violence prevention program; monitoring, reporting and investigating workplace hazards related to violence; providing violence prevention training and education to employees; and devising workplace violence response plans.
Weapons Detection Systems and Other Prevention Steps
Parkland Health has introduced weapons detection systems that use a combination of sensors, AI and machine learning to analyze real-time data and minimize false alarms.
“Weapons detection systems are more than just metal detectors,” says Garvey. “These are the same kinds of systems often used at sporting facilities, concert venues and department stores.”
There was a dramatic decrease of weapons coming into Parkland Health during the first year after implementation. This was due not just to the weapons detectors, but also to increased public signage discouraging violence against healthcare workers, Garvey notes.
Here are a few other steps taken at Parkland Health to combat workplace violence:
- Improved building envelope with access controls, badge readers, dome mirrors and enhanced lighting in dark spaces.
- Implementation of interior and exterior video surveillance.
- Implementation of an aggression tool in the Emergency Department that allows the triage nurse to assess patients for potential behavioral aggression during the healthcare episode.
- Refreshed signs across the healthcare system that outline clear behavioral expectations for patient and visitors.
- An updated incident reporting system that includes a tile for workplace violence.
- Required de-escalation training for certain staff, such as those working in the Emergency Department, Behavioral Health and Correctional Health. The training is also available to any other staff member who wants to participate.
- Soft uniformed (polo shirt and khakis) armed police officers with mental health training who round on known high-risk and aggressive patients and visitors while also providing support to the staff.
- Rounding by executive leaders to make sure they are engaged and knowledgeable about workplace violence and its impact on the staff.
Garvey notes that Integrated Behavior Expectation letters are sent to patients and visitors who have exhibited aggressive behavior toward staff. “These letters are the least intrusive way to address this kind of behavior and have been highly effective,” she says.
“We query staff annually to obtain feedback on our workplace violence program and where there are opportunities for improvement,” adds Garvey. “And we conduct root cause analyses on serious harm events to determine additional steps that can help prevent them from recurring. The outcomes of these cases are shared with workplace violence committees, along with executive leadership and our board of managers.”
Buchert encourages healthcare staff to become advocates for a safe work environment that is free from the threat of violence.
“As an advocate, your voice carries strength,” he says. “In the same way that we advocate for our patients, we must also advocate for our own safe work environment.”
