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Hospitals Fight Back Against Violence

(from the December 2017 ACP Hospitalist)

Workplace violence occurs so often in the hospital that some health care workers consider it part of the job.

Gordon Lee Gillespie, PhD, DNP, RN, estimates that he was assaulted at least 100 times in his first five or six years working as a nurse in the ED. “I wasn't watching those cues that a person's starting to escalate, so I had myself in risky situations,” he said. “And because I was the only male nurse in the ED and the only male nurse in the building for a while, any patient that was aggressive became my patient automatically.”

But dealing with violence should never be considered normal, said Dr. Gillespie, associate professor at the University of Cincinnati College of Nursing. “I personally had the belief when I started practicing that it was,” he said. “The challenge is that in health care, people look at it and say, ‘Well, it's not really their fault,’ but the behavior is always inexcusable.”

From 2002 to 2013, incidents of serious workplace violence were four times more common in health care settings than in private industry, according to the Occupational Safety and Health Administration (OSHA).

“The general incivility and violence in our society has just spilled over into all of our settings,” said Mary Beth Kingston, RN, MSN, executive vice president and chief nursing officer of Aurora Health Care in Milwaukee. Health system policy has encouraged a safe environment for caregivers since the ‘90s, but the language was strengthened two years ago to focus on a “no-tolerance” approach to violence in the hospital, she said. “People were like, ‘Finally, someone's on top of this,’” Ms. Kingston said.

Hospitals have commonly offered employee training and education about workplace violence risk factors and scenarios, but more of them are now going beyond the basics to tackle the problem. New approaches to preventing and mitigating violent incidents include unit-specific interventions and using the electronic health record (EHR) to follow patients involved in prior disruptive incidents.

Hospital hotspots

Within health care, hospitals are particular hotspots for workplace violence. In 2015, medical and surgical hospitals, nursing and residential care facilities, and ambulatory health care settings were among the industries with the highest prevalence of nonfatal occupational violence, with respective incidence rates of 6.0, 6.8, and 2.4 per 100 full-time workers, according to the U.S. Bureau of Labor Statistics.

These figures only represent the number of reported cases, and health care workers often do not report incidents of workplace violence, which includes verbal threats, harassment, and intimidation in addition to physical assaults, said Ms. Kingston. “If someone's not physically hurt, I think that in the past, they haven't had that recognition that this still has an impact on you,” she said.

Among victims of workplace violence in health care settings, just 30% of nurses and 26% of physicians go on to report the incident, according to a 2016 review article in the New England Journal of Medicine (NEJM).

The vast majority of hospital violence is perpetrated by patients or their visitors, as opposed to staff or outsiders, according to the 2017 Healthcare Crime Survey, produced by the International Association for Healthcare Security and Safety Foundation. The most common characteristic among those who initiate violence in the hospital is altered mental status, associated with dementia, delirium, substance intoxication, or decompensated mental illness, according to the NEJM article.

No health care worker is immune to violence in the hospital, but nurses are at particularly high risk, as are ED and psychiatric ward staff. In a national survey of 263 emergency medicine residents and attendings, researchers found that 78% of participants experienced at least one act of workplace violence in the last 12 months, with 75% reporting verbal threats and 21% reporting physical assaults, according to results published in 2011 by the Journal of Emergency Medicine.

Among participants in the Minnesota Nurses' Study, the yearly incidence of verbal and physical assaults was 39% and 13%, respectively, according to a 2004 study published in Occupational and Environmental Medicine. Yet only 27% perceived violence to be a problem at work.

These days, however, nurses are becoming more aware of what constitutes violence, Dr. Gillespie said, giving the example of an elderly woman who gets confused and slaps someone. “There's no intention. But it's not the intent that denotes violence; it's the actual behavior,” he said. “I think as people become more savvy on what the definition is, then the perception is going up.”

Beyond the human toll, workplace violence in the hospital is financially costly. Hospitals spent an estimated $1.1 billion in security and training costs to prevent violence within their facilities, plus $429 million in medical care, staffing, indemnity, and other costs resulting from violence against hospital workers, according to a 2017 report commissioned by the American Hospital Association.

Read the full article in ACP Hospitalist.

ACP Hospitalist provides news and information about hospital medicine, covering the latest trends and issues in the field.

Back to the January 2018 issue of ACP IMpact