Developing a program for dealing with violence in healthcare facilities

The policy should also specify actions that are grounds for termination or discipline e. Mandatory reporting. A mandatory reporting policy requires all staff to report any actual or threatened physical or verbal assault without delay ACEP "Protection".

A nonretaliation policy should explicitly forbid any adverse employment action e. Response to violence. Procedures for responding to incidents of workplace violence should clearly address designated employee roles and responsibilities for notifying managers and security, activating emergency response codes, and incident reporting.

All employees should receive instruction on these procedures. To determine a healthcare facility's risk of violence and develop prevention strategies, risk managers should partner with the security department to conduct a review of facility and community records and statistical crime rates. An internal or external event reporting system can be instrumental in this assessment.

By looking for patterns and determining root causes, risk managers can glean insights into vulnerabilities. Risk managers should not only review documentation of previous violent acts within the facility but also collect statistics on violent gang activity, drug abuse, and other such issues in the community.

Records for review include existing documentation, such as the OSHA log, union information, incident reports, workers' compensation or other insurance reports, minutes from safety and risk management meetings, security reports, and suggestions from employees.

OSHA "Caring" Risk managers can ask the local police department and emergency management services to provide a community crime profile, which should include the number and types of criminal offenses committed in the vicinity of the facility and the times of day when incidence of violent crime is the highest. Risk managers can also consult local businesses and other area healthcare facilities about the amount of violence in and around their establishments, read national news for trends in violent crime, or research U.

Bureau of Labor Statistics data to identify trends in comparable locations with similar populations. Self-Assessment: Violence Prevention.

To get a more complete list of possible risks, risk managers may conduct a survey asking workers, volunteers, and contractors to identify specific violence risks or concerns.

For example, while there may be no history of assaults in the parking lots, employees may be afraid to walk there after dark. Once analyzed, data should be used to inform an appropriate action plan and communicated accordingly. For example, it would be helpful for staff to know whether threats have been made against physicians or that the organization serves a high number of patients from correctional institutions.

HCPro However, such information would likely be alarming in the absence of an appropriate organizational response.

Risk managers can also use the self-assessment questionnaire Violence Prevention to identify strengths and weaknesses and improve the organization's violence prevention program. Uncertainty, grief, and frustration experienced by patients' family members and friends can translate to physical or verbal aggression toward staff members, patients, or others.

For example, in Alabama in , a year-old man who was reportedly unhappy with the care that his wife—a cardiac patient—was receiving arrived at a hospital at 4 a. The man opened fire, shooting a police officer and two hospital employees. Police returned fire and the man was killed. See our response. Violence may also be committed by distraught family members of patients who have died or who have been discharged from the hospital.

In a widely publicized incident, the son of a former patient shot and killed his deceased mother's cardiologist in an exam room at a Boston hospital. According to published reports, the man arrived at the cardiologist's office without an appointment, demanding to meet with the physician.

The cardiologist agreed, and for more than half an hour he answered the man's questions about a drug that had been prescribed to his mother before her death.

After 15 minutes, the cardiologist dismissed his physician's assistant, requesting that she check on other patients. Twenty minutes later, shots were heard from behind the door of the exam room. The cardiologist emerged injured and collapsed.

The patient's son killed himself. After eight hours of emergency surgery, the physician died. Although cases of family violence may be difficult to prevent, healthcare staff can look for warning signs that may indicate an increased risk of family violence and take steps to de-escalate a family member's behavior. For example, family members who are excessively stressed may exhibit early warning signs such as rapid pacing, excessive fidgeting, shouting, or depression Barthel; Barboza and Zarembo.

In some cases, taking family members to a safe, quiet area to help calm their emotions or arranging a meeting with a supervisor to help answer the family members' clinical questions can help defuse emotions Barthel.

In addition, a family member who spends most of his or her time at the facility, who visits the facility at odd hours, or who attempts to access restricted areas of the facility may be more prone to violence Barboza and Zarembo; Kaldy.

For more information on recognizing potentially violent behavior, and use of de-escalation techniques, see Patient Violence. Patient Violence. Patients who present to the hospital ED may be there because they have been injured by their spouse or partner, who may follow the patient to the healthcare facility and cause a violent episode. Identifying a victim of intimate partner violence can be challenging because clinical presentation varies widely.

However, providers can include screening questions for domestic abuse in the intake process during discussion of the patient's medical history, social history, or history of present illness, whichever seems most appropriate and is most comfortable for the provider. See Intimate Partner Violence for more information. Healthcare workers may themselves be victims of intimate partner violence and could be targeted at work by their abusers i. Supervisors should be trained to detect warning signs that employees are experiencing domestic violence and to refer employees to the employee assistance program EAP.

Some common signs that should raise a supervisor's suspicion that an employee may be a victim of abuse are as follows "Protecting Domestic Abuse Victims" :. Patients or healthcare workers may also become victims of stalking. Patients are particularly vulnerable while in a hospital bed. Patients should be encouraged to report threats against them during the intake process e.

Patients who report being threatened or stalked should be placed in a room that can be easily and constantly monitored. Of course, this type of information must be treated as confidential. Only with assurance of confidentiality will patients or healthcare workers come forward with this information.

The following actions have been recommended if an employee is being threatened or stalked Kelley; Kinney :. Worker-to-worker violence includes physical assault, verbal aggression, harassment, intimidation, threats, and bullying. It may be perpetrated by senior staff towards junior staff, or between employees of the same professional rank e. Hamblin et al. The majority of incidents did not involve physical violence; however, some did, such as the following situations Hamblin et al.

A study of violent incident reports from a large hospital system's human resources database revealed perpetrator characteristics of worker-to-worker i. Researchers found that perpetrators of type 3 violence in healthcare were typically female, full-time workers and were more likely to be nurses or patient care associates. The following were identified as the five most common perpetrator-target dyads Hamblin et al.

Substance Use Disorders in Nurses. Healthcare organizations must take precautions to minimize the risk of violent behavior from staff members. The stressful healthcare environment can increase the chance that individuals who usually do not demonstrate violent tendencies will act violently. Drug and alcohol abuse to which many healthcare workers may be vulnerable owing to the stressful nature of their occupation exacerbates the risk.

However, employees generally do not just "snap"—red flags usually appear first. Supervisors and employees should be advised of signs that an individual may become violent. Staff should be educated about warning signs of potential violence and instructed to inform their supervisor if an employee exhibits any of these indicators of potentially violent tendencies.

The supervisor should maintain confidentiality by first talking to human resources staff or a representative from the EAP about the staff concerns and behaviors that have been reported. However, if the healthcare worker is creating a hostile work environment—or if the reported behavior poses an immediate threat to patient or staff safety—the behavior must be addressed immediately.

Supervisors should refer employees who exhibit warning signs of potential violence to the facility's EAP for assistance when appropriate. As discussed above, healthcare workers and staff members not normally prone to violence may unpredictably lash out due to workplace or personal stressors.

EAPs can contribute to minimizing the risk of this type of violence and may offer individual counseling or family counseling. A healthcare worker who is fired or disciplined could potentially perpetrate retaliatory violence, especially if he or she exhibits indicators of violence before the firing or disciplinary action.

Risk managers should ensure that supervisors give all employees notice of organizational policies and procedures and the corresponding disciplinary actions for violation. This forewarning can prevent employees from feeling singled out if disciplined. If an incident that may require discipline or termination occurs, supervisors should investigate the situation to get the employee's side of the story, and ensure consistency in the treatment of all employees.

Supervisors should be trained in how to discipline and fire employees without triggering a violent outburst and should partner with human resources staff. Proskauer Rose. Healthcare organizations may consider providing job counseling through the EAP for terminated or laid-off workers. This shows that the organization cares, and it may reduce hostility levels. When potentially violent or highly disgruntled employees must be terminated, staff may prevent a violent response by making eye contact, by allowing the employee to communicate his or her feelings, by listening attentively and paraphrasing what is being said, by empathizing but not apologizing, and by always asking if the employee has further questions before closing the meeting Johnson et al.

After the employee's termination, a security officer or member of management should be available to escort the employee back to his or her desk and then to the door of the building. Identification cards and badges should be returned, computer identification passwords should be deleted from the system, and methods for access to the building or campus should be changed as necessary. The facility may also wish to organize a meeting with staff members to inform them of the termination without providing confidential or unnecessary information and remind them of which procedures to take if they notice a terminated employee near the facility or campus.

Purposeful patient harm is a rarer, more sinister manifestation of violence by healthcare workers. Most healthcare workers are dedicated, caring individuals; however, no organization is immune to an exception. In total, 19 women, including patients and hospital staff, alleged abuse by the physician. The physician pled guilty to 11 counts of sexual abuse and one count of rape; he was sentenced to 23 years in prison.

Criminal Background Checks. Enforcing stringent background check procedures is key to preventing patient harm. One of the most accurate predictors of harmful or violent behavior is a history of violence or implication in a suspicious patient injury or death.

If an event involving employee violence does occur, it is important, from a liability standpoint, for the healthcare facility to be able to show that it did everything in its power to screen out employees with a violent past.

For a more detailed discussion on conducting background checks, refer to Criminal Background Checks. Healthcare employers whose workforce includes healthcare providers and practitioners obtained through temporary staffing agencies may have a duty to ensure that the temporary employment agencies they use have obtained criminal background records.

For more on this topic, refer to Employing Temporary and Agency Staff. However, background checks are not foolproof safeguards against hiring employees who may become violent. Risk managers must work with supervisors to ensure they treat employee reports of suspicious behavior seriously, investigate reports thoroughly, and never react negatively toward the reporting employee.

In alarming cases, workers continued to maliciously harm patients because warning signs went unnoticed or were ignored by other employees, supervisors, and healthcare facility administration. Despite the prevalence of violence in healthcare, research on prevention has not yielded universally applicable strategies for risk reduction Phillips.

However, OSHA has identified the following five core elements of a comprehensive workplace violence prevention program that can form the basis for organization-specific prevention strategies OSHA "Caring" :.

Leaders, supervisors, and staff each play critical roles in the development and execution of a robust workplace violence prevention program.

According to OSHA, leaders should begin the development of a workplace violence prevention program by convening a planning group or task force to collect baseline data, plan, implement strategies, and monitor the program. Whoever leads the group should have the appropriate knowledge base and the appropriate authority to effect the necessary changes. Leaders should also build a multidisciplinary threat assessment team, which often includes representatives from the behavioral sciences, security or law enforcement, labor union s , high-risk areas, staff education, patient advocates, and legal counsel.

Typically, an organization's chief medical officer leads such a team with support from senior clinicians e. Wyatt et al. In addition to establishing a violence prevention program and a threat assessment team, leaders can demonstrate commitment through the following actions Wyatt et al.

Supervisors and staff. OSHA also cites the importance of a "participatory approach [in which] employees and management work together on worksite assessment and solution implementation. OSHA "Caring" As the individuals on the front lines of care and interaction with visitors, family members, and coworkers, direct care workers have valuable input on the problem of workplace violence. When supervisors engage staff to review incidents of violence, they should discuss how situations fall outside of established norms and strategize to prevent future incidents.

The benefit of this collaboration is twofold: First, supervisors will promote a culture of civility and empowerment in the workplace; in so doing, supervisors will also help to prevent future harassment or violence. A team including clinical and nonclinical employees, security staff, supervisors, and senior management should assess risks for workplace violence through a workplace security analysis, record review, employee surveys, and job analysis.

A workplace security analysis, or "walk-through," should cover all internal and external areas, with a special focus on areas identified as high risk. The assessment team should include frontline healthcare workers with nurse representatives from each unit and safety and security professionals. During the walk-through, employees may be questioned about relevant details. The team should try to assess issues such as prevailing style of management, areas of excess stress, and ways in which individuals organize their duties.

Attention should be given to questions such as the following:. Workplace Violence Prevention Plan. On holidays and third shifts, staff shortages may make organizations more vulnerable to violence. During emergencies, people are usually so involved with response efforts that they may forget procedures that protect against violence.

The self-assessment questionnaire Violence Prevention and sample policy Workplace Violence Prevention Plan can be used to further identify and document the strengths and weaknesses of the facility's violence prevention program.

Once hazards are identified, OSHA recommends addressing them with a combination of engineering controls and administrative and work practice controls. Brief examples of engineering controls—physical changes to the workplace—include the following OSHA "Caring" :. Examples of administrative and work practice controls—changes to the way staff perform their jobs—include the following OSHA "Caring" :.

See Hospital Security for a detailed discussion on hazard prevention and control in the healthcare workplace. Training is an essential component of any comprehensive workplace violence prevention program, so that staff are competent to recognize warning signs, know how to respond, and are confident in doing so.

OSHA states that many training programs, policies, and procedures focus only on violence committed by patients, and in so doing fail to address violence by employees, random criminals, and perpetrators of intimate partner violence. Therefore, risk managers should ensure that training covers all types of workplace violence as opposed to only violence perpetrated by patients against employees.

Although the importance of training the workforce in policies and prevention strategies may seem obvious, these steps cannot be taken for granted. Researchers found this result to be in concurrence with other reports on training of ED physicians Schnapp et al.

Similarly, in a study of workplace violence prevention programs at California home care and hospice agencies, only Gross et al. Although all staff, affiliated physicians, and contract workers should be trained in prevention and response to workplace violence, training should also be tailored according to duties and work locations. OSHA recommends customizing training to the particular needs of nurses and other direct caregivers, ED staff, support staff, security personnel, and supervisors and managers.

For example, supervisors and managers, who have higher levels of responsibility as agents of the employer, should be trained separately from staff; they should be informed that all reports of suspicious behavior or threats must be treated seriously and thoroughly investigated. Areas for emphasis include the following Hamer :.

Security personnel are critical responders in violent or potentially violent situations. They should receive specialized training to address "the psychological components of handling aggressive and abusive clients" and instruction in techniques for managing aggressive individuals and defusing hostile situations. OSHA "Guidelines". The most successful training programs for workplace violence prevention utilize a variety of formats including classroom training, hands-on instruction, real-time i.

Although OSHA acknowledges several advantages of web-based training, the agency recommends blending any remote training format with live instruction and practice opportunities—essential elements for skill building. OSHA "Caring" Such in-person training provides critical opportunities for employees to practice individual roles and responsibilities as delineated by organizational policy for violence prevention and response.

Because violence management training is learned, not innate, practice and refresher training are critical to maintain learned skills.

Employee reporting of incidents and near-misses is a critical first step for accurate record keeping and program evaluation. Yet, underreporting is a challenge. Leaders and supervisors should stress the vital importance of record keeping as a foundation for program evaluation, to assess program efficacy, identify overlooked hazards, establish training needs, and pinpoint additional preventive measures OSHA "Caring". See Encourage Reporting for more information.

Reporting, which is critical to the success of a workplace violence prevention program, depends on efficient and effective event reporting systems from which leaders can glean insights for intervention and prevention Wyatt et al. However, underreporting of workplace violence by healthcare workers is a major issue. Employees may fear supervisors will blame them or minimize the seriousness of an incident; they may also be reluctant to cause tension, or they may blame themselves. The reporting of workplace violence in a seven-hospital system with approximately 15, employees was studied using a subset of data from the organization's electronic incident reporting system, which included only workplace violence events.

The products below: Workplace Violence in Healthcare: Understanding the Challenge , presents some estimates of the extent of the problem from various sources; Preventing Workplace Violence: A Road Map for Healthcare Facilities expands on OSHA's guidelines by presenting case studies and successful strategies from a variety of healthcare facilities; and Workplace Violence Prevention and Related Goals: The Big Picture explains how you can achieve synergies between workplace violence prevention, broader safety and health objectives, and a "culture of safety.

An executive summary for hospital administrators and others who want to learn more about the prevalence of workplace violence in healthcare, associated costs, key risk factors, and what organizations can do to address the problem. PDF Download. This "road map" uses real-life examples from healthcare organizations to illustrate the components of a workplace violence prevention program. Learn how other healthcare facilities have addressed this challenge and discover resources that are available to help your organization develop and implement your own program.

Learn how preventing workplace violence can go hand-in-hand with strategies that your organization might already be using for compliance, accreditation, worker safety and quality patient care.

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