Synopsis: Healthcare workers are about four times more likely than workers in any other field to be attacked on the job, usually by patients or family members, and most often in the emergency department. Experts discuss how and why attacks occur and how hospitals and health care workers can do a better job preventing them.

Host: Reed Pence. Guests: Lisa Wolf, Director, Institute for Emergency Nursing Research, Emergency Nurses Association.; Dr. Christopher Michos, Connecticut emergency medicine physician; Dr. Ronald Wyatt, Medical Director, Division of Healthcare Improvement, The Joint Commission

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Violence Against Healthcare Workers

Reed Pence: Most people don’t lose sleep worrying about being injured on the job. Hazards vary widely from one job to another, but one danger most of us don’t think about is being attacked by the people we serve. Unless you’re in healthcare.

Wolf:  I don’t think I know a colleague who has not had some physical encounter with a patient over the course of their career.

Pence: Lisa Wolf is director of the Institute for Emergency Nursing Research at the Emergency Nurses Association.

Wolf: In the study that we’ve done at the Emergency Nurses Association did, what we found was 56.7% of nurses recorded having been physically assaulted or both physically and verbally assaulted in the previous seven days.

Michos:  In 2014 there was a survey of emergency medicine nurses that recorded that 80% of EM nurses report being attacked within the past year. A survey conducted by our Association of Emergency Medicine Physicians noted that one-quarter of emergency medicine physicians report that they’ve been victims of physical assault in 2012.

Pence: Dr. Christopher Michos, a longtime emergency physician in Connecticut, says studies show the rate of violence perpetrated against healthcare workers is nearly four times that of other industries. The federal Bureau of Labor Statistics says that of the more than 25,000 significant injuries per year reported nationally as a result of workplace assault, nearly 70 percent of them are in healthcare.

Wyatt:  I have been verbally assaulted. I’ve been pushed, slapped, punched, bit on. I had a gun held at me, and have been held hostage.

Pence: That’s Dr. Ronald Wyatt, a practicing internist for 25 years, who now tracks this issue as medical director of the Division of Healthcare Improvement for the Joint Commission. That’s an accreditation agency for hospitals and other healthcare institutions. Wyatt says assaults occur most often in the emergency department. And patients are the biggest source. Wolf agrees.

Wolf:  Those include patients who are impaired as they come in, and patients who come in from violent encounters to start with. So if your patient comes in in hand cuffs with the police because they assaulted someone, chances are good that they might be violent in your department as well. We see this also in patients who are under the influence of alcohol or drugs. A lot of times they don’t want to be in the emergency department; they are very focused on getting out of the emergency department. But we do see also the environment itself can provoke feelings of frustration that result in verbal or physical confrontation. Those are things like really crowded waiting rooms, long waits, situations where there’s an unexpected death in the emergency department and family members are angry, they’re upset. So that can spill over into a violent encounter as well.

Pence: Wyatt says reported violence against healthcare workers is up by about 50 percent in just the last three years. But Wolf says there are only theories as to why.

Wolf:  Certainly I think that violence has become somehow more an accepted solution to peoples’ frustration. There is some discussion that the focus on customer service has made patients have fairly unrealistic expectations of what their emergency department care will look like in terms of speed and disposition. People are in the emergency department, they’re upset that they haven’t been seen within 15 minutes. That’s just not always possible. So to provide realistic expectations of the length and the course of care is important. I think that because more and more people come to an emergency department it gets crowded and the wait times get longer. Certainly if you’re there for a sprained ankle and we have someone coming in in cardiac arrest, well, we take the sickest people first and that gets people upset.

Pence: Nurses and doctors can often see violence coming in a patient who’s drunk or demented. But occasionally, and much more dangerously, bereaved family members may plot retribution against doctors who they think botched their loved one’s care. Wyatt had fears it was happening to him a few years ago when he walked into an exam room for a new patient visit — an older woman accompanied by her husband.

Wyatt:  When I walked in she reached in the shopping bag and pulled out this really large photograph of a former patient of mine. I immediately recognized the patient. How could I not? Because she was a young woman who died quite unexpectedly. I said to them, “I can’t talk to you about this patient.” At that point the gentleman moved behind me, and in a soft voice he said, “You’re going to talk to us, or you’re not going to leave this room.” I did not have in that setting any way to alarm the staff. What I choose to do was sit and talk to them. One of the concerns was well, if this guy has a gun, or she has a gun in the bag, then I’m going to put other people at risk if I start to fight with them to get out of that room.    

Pence: Wyatt eventually showed the couple computer records detailing the efforts he and his staff had made to save their daughter. The couple left, and Wyatt never saw them again. The incident points up the fact that private rooms can be safety hazards. Wolf says it’s most acute in emergency departments.

Wolf: When I started working in emergency departments it was a horseshoe with curtains. You could see all of your patients. Nobody was hidden. Now there’s this push for privacy and that’s all very good for patient care, but you’re stuck behind a door and your colleagues can’t see you and they can’t hear you. It’s a little bit scarier to go into a room with a patient. The thing is with nursing, which is different from other professions, is that we have to get into peoples’ personal space in order to do our job. If you’re angry and you’re under the influence, I still have to take your blood pressure. I still have to get a blood sugar. I still have to touch you; I have to get within reach where I can be hurt.

Pence: In fact, seriously hurt. Violent patients have clubbed nurses with steel bars ripped from beds. Punching or kicking is common. So there are plenty of injuries, both physical and psychological.

Wolf: People have real psychological residue, they get really skittish. They refer to it as almost a PTSD like phenomenon. They go back to the room where they were physically assaulted and they sweat, they have panic attacks. People have lasting physical sequela – a torn rotator cuff, concussion, broken arm. Again, not nearly as common as more, you know, I’m going to put air quotes here, minor injuries, like being bitten or being slapped, but in what other occupation where you’re helping people are you expected to take abuse from those people? Also, I think what’s important to note, a third of emergency nurses considered leaving their department or nursing altogether because of violence.

Pence: So what can nurses and doctors do short of walking out the door? What should hospitals be doing? Many of them post guards in the emergency department. Electronic medical records may flag patients as having been violent on previous visits. And healthcare workers like Michos need to keep their safety front of mind.

Michos:  I think about it. I’m concerned about it. It’s modified my behavior in terms of making sure that I look around if I’m feeling or confronting a potentially hostile situation or hostile patient. I make sure that I have adequate resources available to me. We’re increasing our use of sedatives for violent patients these days. We’re also increasing our use of restraints. But if I sense at any moment that this is going to become a violent situation or put myself or the staff at risk, I’ll call the appropriate code alert to bring security and resources to the department to either restrain the patient or just to have a show of force to protect myself and staff members and the patient.

Pence: But Michos and Wolf agree that’s not enough.

Wolf: People talk a lot about having appropriate security. That is so far down the road that it seems worth it to me to invest some effort into the initial recognition and mitigation of escalating patients and families than it does to worry about whether my security guard has a gun in my crowded emergency department.

Pence: Recognizing threats takes education. A handful of states mandate training, but Wolf says a surprising number of hospitals don’t offer any.

Wolf: Eighty-one percent of nurses report having taken a course on handling workplace violence. Only about half of hospitals provide the training. So hospital security and managing patients becomes a very reactive process. In other words, this is not part of the basic training for nurses. I taught in various nursing programs in both New York and Massachusetts for 10 or 11 years. This was never part of the curriculum. I think it’s really important especially for younger or newer nurses, to understand when things are starting to escalate. I don’t think people get adequate training on that.

Pence: But if violence is such a serious issue, why isn’t training routine? Apparently, some hospitals don’t think the issue is all that serious. Some don’t even think it happens at their institutions. Mandatory reporting of every incident opens eyes to how often it goes on and often forces preventive action. That’s why Wyatt says reporting is a powerful risk reduction technique. But where it’s not mandatory, nurses often don’t report violent incidents. Wolf says that’s typically because when they do report something, nothing changes, so why bother? Surveys by the Emergency Nurses Association show that nurses believe that hospital administrators don’t care.

Wolf:  They continually brought security issues to the attention of their administration and it went unheard. The recurring question that came up in these was, who has to die? What nurse has to get killed in order for administrations to take this seriously? I think that nurses feel like they need that kind of administrative support that they’re not getting. They report security cameras that haven’t worked in two years. They report panic buttons that nobody comes. When your security team is one guy for your whole hospital, there’s not a lot that you can count on if something starts to get dangerous.

Pence: But if that’s true, why don’t hospital executives do more? Here’s what nurses believe administrators think:

Wolf: Part of it that came out in this qualitative study was that it is assumed that this is part of the job. There is this underlying assumption that the emergency department is a violent place and if you work there and you get hurt, you shouldn’t have expected anything different. This is what people report happened to them when they ask that their hospital security to help them file charges against violent patients. Police, judges – they’ve had people say to them, “Well you work in an emergency department. What do you expect? So I think that is the biggest barrier that there is this cultural assumption that it’s part of the job and that we should just accept that as a risk.

Pence: So if hospitals really want to prevent assaults on their employees, Wyatt says it starts at the top.

Wyatt: Leadership is at the table. They’re not saying, “Go have a meeting on this every quarter and let me know what you decided.” Leadership has to be at the table actively engaged in the entire process if you want to build what we call a robust workplace violence prevention program. So that multiple facets of it — and it has to be continuous — it can’t be a one off, one time you get training, one time you do a simulation, we train you when you’re hired and then a year later. It has to be a more proactive approach, because after all we’re talking about prevention.

Pence: If nothing else, hospitals should get serious about violence against their workers because of the economics. If nurses quit due to violence, that’s a huge amount of skill and experience walking out the door. And according to the government’s Occupational Safety and Health Administration, about a third of employees’ sick leave due to injury results from a patient’s attack. You can find out more about all our guests on our website, I’m Reed Pence.


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