Violence in the Workplace

Sometimes it takes a new set of eyes to recognize an entrenched cultural norm that is failing healthcare staff and patients. A few weeks after assuming the CNO position at Aria-Jefferson Health, Philadelphia, Michelle Conley, RN, heard “Code Armstrong” announced over the intercom, indicating a violent situation in the ED.

 

When Conley arrived in the ED, the incident was over, and staff were calmly going about their jobs. “I asked the charge nurse what happened,” Conley remembers, “and he said something like, ‘Nothing to worry about. Everything’s taken care of.’”

 

When Conley pressed for information, she learned that an ED nurse had been repeatedly kicked in the head by a patient and suffered a concussion. Other nurses had intervened to help while a security guard stood by.

 

“A couple things struck me about the situation,” Conley says. “One was that nobody thought it was a big deal. Second was that this type of violence seemed commonplace. People had become so desensitized to these events.”

 

This was in 2012 when workplace violence was not yet on the radar of many healthcare leaders. In the intervening years, the magnitude of the problem has been called out by federal agencies, associations and industry watchdogs. Healthcare workers are four times more likely to be victims of violence than workers in private industries, according to the U.S. Occupational Safety and Health Administration. The great majority of violent incidents—92 percent— involve patients or other customers such as family members.

 

Although challenging, it is possible to dramatically reduce workplace violence. For instance, Aria-Jefferson decreased violence-related injuries by 70 percent between 2012 and 2016. In another example, the VA Portland Health Care System reduced the number of violent episodes among patients with histories of disruptive behaviors by 91 percent.

 

The secret behind these successes is that there’s not one solution. Instead, multifaceted initiatives backed and supported by senior executives are needed. “A lot of people think that you only need to roll out a few changes, like provide de-escalation training or make some environmental changes,” Conley says.

 

“While each separate strategy is important, it was our comprehensive approach— which took no less than two years to implement—that really made an impact. This was not easy or cheap.”

 

Here are seven strategies that healthcare leaders cite as critical in any comprehensive campaign aimed at reducing violence, particularly incidents involving patients and other customers.

 

Though a great deal of information is available to give leaders a big-picture understanding of workplace violence (see Sidebar 1, on Pages 18 and 19), nothing replaces the specific insights provided by front-line staff at one’s own organization. Diane E. Allen, RN, FACHE, retired assistant director of nursing at New Hampshire Hospital, Concord, N.H., can attest to that.

 

A long-time nurse at the state-funded inpatient psychiatric hospital, Allen has seen her fair share of patients with violent tendencies. Because the local criminal justice system is over- stressed, criminals with mental health problems and violent histories are frequently admitted.

 

In 2007, Allen knew things were get- ting out of hand when her staff asked for more training in how to physically restrain aggressive patients. “Our nursing staff are screened for their ability to communicate, to be kind and empathetic, not for their physical size or strength,” she says. “We didn’t want our staff wrestling with patients.”

During a series of focus groups with staff, leaders learned a lot about the root causes of violence at New Hampshire Hospital, which often stemmed from patient frustrations related to situations such as:

To address these issues, hospital leaders encourage staff to follow four simple guidelines:

In addition, the hospital started tracking violent incidents. Data pulled from workers’ compensation claims revealed that 40 percent of staff injuries occurred during physical interventions with patients—trying to get people to do things they didn’t want to do or stop them from doing harmful things. Allen attributes this to a “superhero complex” that existed among staff, particularly unlicensed mental health workers. When asked which title was included in their job descriptions—bodyguard, professional wrestler or superhero—the aides laughed. But almost all chose “superhero.”

 

“They insisted it was their job to make sure nothing bad happened to patients, nurses or doctors. It was their job to physically protect them, even if they had to sacrifice their own personal safety,” Allen says. “That was a real ‘aha’ moment for us as leaders.”

Soon after Aurora Health Care, Milwaukee, now Advocate Aurora Health, formed a steering committee to investigate workplace violence, members realized the health system did not have a values statement clearly stating the organization’s position. “We had policies about what to do in cases of violence, but we didn’t have a statement saying we don’t tolerate violent behavior in the work- place,” says Mary Beth Kingston, RN, executive vice president and CNO. “That might seem like a small thing, but developing that statement allowed us to start creating a work- place that works to prevent and address violence.”

 

The Aurora Health Care statement covers both physical and nonphysical aggressive acts (e.g., bullying, harassment, punching, pushing). This reflects the broad definition of work- place violence adopted by The Joint Commission in an April Sentinel Event Alert.

 

Nonphysical violence is common in healthcare, and that high prevalence contributes to staff burnout and turn- over, explains Patricia McGaffigan, RN, vice president, safety programs, Institute for Healthcare Improvement, and an ACHE Member. “People will say after years of dealing with nonphysical violence such as bullying and incivility, ‘I’m not the same person I once was,’” she says. “Nonphysical violence can reduce workers’ resiliency and make it harder for them to be situationally aware and give patients and families the best care.”

 

After senior leaders at Aurora Health Care signed off on the zero tolerance for violence statement, a communications campaign was launched to push out the message to staff. A sign also was placed in system EDs stating that the hospital is “a place of healing” and does not tolerate violent behaviors. “I don’t think any patient who’s in an aggressive mode will see the sign and react by calming down, but the signs send an important message to our staff that we’re setting this expectation and this is the type of environment we want to create,” Kingston says.

 

Because troubling cultural norms about workplace violence (i.e., “it’s part of the job”) were deeply entrenched at New Hampshire Hospital, it took leaders years of consistent messaging to get mental health aides and nurses to stop intervening alone in potentially violent situations. “It was a lot of talking,” Allen says. “Every opportunity we got, we re-emphasized that we didn’t want them to get hurt.”

 

New procedures also were developed for staff to follow whenever they felt in harm’s way. Before physically intervening with any patient, staff are supposed to seek assistance from at least five other clinical staff and develop an intervention plan. A Code Gray should be issued over the inter- com to alert clinicians, as well as security, that help is needed.

 

At first, only mental health aides were taught the new procedures, which didn’t go over well. “They muttered under their breath and looked at me like I was out of my mind,” Allen says. Feeling singled out, the aides told Allen to go “talk to the nurses” about the new procedures. The nurses, in turn, said “talk to the physicians.”

 

After physicians recommended making the procedures hospital-wide, the Staying Safe training program was born. Now all staff receive training in the new procedures, which are also incorporated into employee orientation.

 

New Hampshire Hospital has seen staff injuries due to patient assaults decline by 70 percent between 2007 and 2017. Restraint use also has steadily declined. Plus, Code Grays have tripled in number since 2007, which means staff are calling for help as instructed.

 

While changing the culture has been key, Allen also credits a healthy collaboration between clinicians and on-campus police. Because the psychiatric hospital is state-run, it is served by a team of state police officers specially trained to respond to individuals with mental illness. The officers answer Code Grays along with clinicians, but they stay in the background and do not intervene unless a nurse asks for help. “We try to be really careful because we are a hospital, and we really don’t want law enforcement to have a role in treatment. But there are situations that exceed our capacity and we need help,” Allen said.

 

A close clinical-security partnership was initially missing at Aria-Jefferson. But when Conley told both the organization’s CEO and COO that 42 staff had been victims of workplace assaults, they supported her push to revamp the security department and hire a security director who wanted to collaborate with clinicians.

 

“Neither the clinical nor the security perspective alone is [sufficient] to address the issue of workplace violence,” Conley says. “You really need that coming together of worlds to make really good decisions about how to move forward and develop interventions that are different than either of us would come to on our own.”

 

The now fruitful security-clinical partnership at Aria-Jefferson began with information gathering. Security Director Darryl Beard, an ACHE Member, pulled additional data on workplace violence, including security and workers’ compensation reports, to review with Conley. Then they conducted numerous focus groups with staff from different units, departments and shifts. This helped them develop a comprehensive work plan focused on addressing workplace violence in five overarching areas:

After talking to staff and conducting an environmental assessment, Aria-

Jefferson security staff identified a list of vulnerabilities at its facilities, including:

This led to a number of environmental changes, including updating cameras, securing patient care areas with card readers and adding metal detectors in hospital ED entryways. Recognizing that the environment extends into the community, Aria-Jefferson’s security department also is building alliances with the local police departments serving the health system’s three hospitals. For instance, one hospital has set up a “stop station” for the police department’s mobile bike unit. When police are on patrol near the hospital, they stop to use the restroom and talk with hospital security staff. “They’re letting us know what’s going on in the community, and we’re let- ting them know what’s going on around the hospital,” Beard says. 

 

Healthcare organizations interviewed also are providing de-escalation training to clinicians and other customer-facing staff. Staff learn how to recognize when a patient or other person is becoming agitated or aggressive, as well as practical response skills (e.g., verbal responses, body language) to prevent the situation from escalating and to keep everyone safe.

 

For example, Aurora Health Care provides different types of de-escalation courses for different staff members. Registrars and other gatekeepers take a four-hour course while ED and behavioral health clinicians take a more in-depth 16-hour course that also covers physical restraint. There is also a special module for home care staff who often are dealing with these situations solo.

 

Aria-Jefferson is putting clinicians and security staff through de-escalation training together so they can role-play real-life scenarios following the health system’s standard operating procedures. “If I’m a nurse, I’m sitting next to a security guard and we’re learning how to intervene together,” Conley says.

 

One takeaway is that a staff person’s role in an intervention isn’t necessarily driven by his or her job category. “If there’s a patient acting out in a certain way, there may be times when the security guard is the absolute best person to intervene,” Conley said. “Other times it may be the nurse.”

 

As an example, Conley remembers one patient who was yelling and throwing chairs and other items around. When unit staff issued a code, security responded as requested but that only worsened the situation. “The patient wanted a fight, so seeing security officers in uniform was exactly what he wanted and only escalated him,” Conley said. The situation ended peacefully after nurses calmed the patient down using various verbal strategies.

 

“We have what we call a tap-out process,” Beard says. “When staff feel like they are unable to de-escalate a patient, they can tap each other [on the shoulder, for instance] and allow somebody else to step in who may have a better interaction or rapport with the individual.”

 

Veterans Health Affairs has been providing de-escalation training to staff since the 1980s to help employees “go from being bystanders of events to

up-standers,” says Lynn Van Male, PhD, director, VHA Workplace Violence Prevention Program. While critical to keeping staff safe, the de- escalation training does not address underlying problems, from socioeconomic to behavioral issues that cause some patients to become agitated or aggressive.

 

“We realized that people who engage in disruptive behavior tend to come back and do it again,” Van Male says.

 

VHA has instituted a closed-loop response system that aims to prevent future violent behavior by addressing each veteran’s case in a comprehensive manner. The loop begins when a staff person reports a patient’s disruptive behavior, either verbal or physical, via an electronic form. This report is then reviewed by the Disruptive Behavior Committee at the VA facility where the incident occurred. These committees are chaired by the facility’s top medical officer and include representatives from the clinical team, VA police, quality management and patient safety and other areas.

 

To assess the safety threat posed by a veteran, committee members use a Violence Risk Assessment Instrument, which is based on decades of threat assessment research into factors associated with violence (e.g., substance abuse, history of stalking), as well as protective factors that lower violence risk. Thanks to an EHR that is integrated with the Department of Defense, committee members are able to pull together various types of information about a veteran’s life and health to complete this assessment.

 

The committee then issues recommendations aimed at helping the veteran and keeping staff safe. Veterans may be offered various resources, from addiction and behavioral health treatment to programs aimed at addressing social determinants of health. Research conducted by the Durham (N.C.) VA Health Care System identified factors that help prevent veterans from engaging in violent behavior, including employment; housing stability; social support; and access to food, healthcare and other basic needs, and found that veterans who had these protective factors were dramatically less likely to engage in severe violence than those who did not.

 

To ensure staff safety, veterans with a history of violence may have limitations placed on when or how they can access healthcare at VA facilities. For instance, the veteran may only be able to get primary care at a specific clinic at certain times of the day when staff who are particularly skilled at dealing with violent individuals are working.

 

Federal law requires the VHA to provide care to eligible veterans regard- less of their behavior. “The last thing we want to do is to ban an individual,” Van Male says. “That not only denies them healthcare, but access to care is one of the protective factors that prevent violence.”

 

The final step in the VA’s response system is communication, which entails informing relevant clinicians and staff about the committee’s recommendations for a veteran. One communication tactic involves adding a flag to a veteran’s record in the EHR, which is intended to warn staff about patients who could become violent so they can prepare and respond appropriately. “The flag is a wonderful technological advance, but first you have to use evidence-based practice to determine whether or not a behavior poses a threat and then customize a safety and treatment plan for that person,” Van Male stresses.

 

After decades of studying how to prevent violence and reduce the use of seclusion and restraint on patients, Allen is convinced that the most powerful antidote to violence is kindness and compassion. “What I’ve learned is that it’s the human connections we make, the trusting relationships we build by engaging people, being kind and helpful, that really keep us safe.”

 

This is not the idealistic perspective of someone far from the trenches. This is coming from a psychiatric nurse who calmly recalls an out-of- control patient breaking off the leg of a chair to wield as a weapon.

But Allen remains a believer in the power that nurses and other clinicians have to proactively build one-on-one alliances with patients who may be frustrated or angry. “I started as a night nurse 24 years ago, and the first thing I always did when I met a new patient was to try to convince them that I was on their side. I would tell them: ‘Look, it’s my job to try to help you get out of here. Let’s talk about what happened and how we can work this out together.’”

 

A Comprehensive Approach
As with any complex problem, work- place violence requires a comprehensive, multi-faceted response. Senior leaders should make it clear that violence—both physical and non- physical (i.e., bullying, harassment)—is not allowed and that healthcare staff are not expected to put them- selves in harm’s way.

 

Healthcare organizations need to develop procedures for responding to violent episodes in all types of set- tings from the ED to home care. Providing de-escalation training to nurses, physicians and other staff is key to curtailing emotionally disruptive episodes that could turn violent. So, too, is a collaborative partnership between clinicians and security.

 

A variety of prevention tactics are being used to reduce the potential for violence, including facility upgrades (e.g., key card access to clinical areas), EHR alerts that warn staff of patients with a history of aggression and outreach efforts aimed at helping patients obtain behavioral health services or addressing social determinants of health. Healthcare organizations that have adopted a comprehensive approach to workplace violence report dramatic decreases in harm to staff.