Workplace Violence Rampant in Healthcare

Veronica Hackethal

April 27, 2016

Workplace violence against healthcare workers is rampant, but solutions remain unclear, largely as a result of underrecognition and underreporting of the problem and poor-quality research, according to a review article published in the April 28 issue of the New England Journal of Medicine.

The article stems from the tragic death of a surgeon at Brigham and Women's Hospital in Boston, Massachusetts, in January 2015. The surgeon was shot and killed by the son of one of his patients, who had died. The homicide gained widespread attention, but follow-up reports failed to represent the full extent of workplace violence in healthcare, according to review author James Phillips, MD, from Harvard Medical School and the Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts.

Far more common than homicide are the daily encounters with lower-level violence, such as verbal abuse, physical assault, intimidation, stalking, and sexual harassment, experienced by healthcare workers but often overlooked.

"Workplace violence with nurses, physicians, and other healthcare workers is a much bigger problem than the general public knows," Dr Phillips told Medscape Medical News, "Healthcare providers also seem to be unaware of the extent of the violence."

The issue needs to be addressed from the start, in medical and nursing school, he says.

"The fact that nurses and doctors are graduating into the most violent industry in the US outside of law enforcement with hardly a mention of that issue, and almost certainly no training regarding those situations, is a gross oversight in my opinion, and one that can be reasonably be addressed with minimal cost," he asserted.

The statistics are alarming. According to studies cited in the article:

  • almost 75% of all workplace assaults between 2011 and 2013 happened in healthcare settings;

  • 80% of emergency medical workers will experience violence during their careers;

  • 78% of emergency department physicians nationwide report being the target of workplace violence in the past year;

  • 100% of emergency department nurses report verbal assault and 82.1% report physical assault during the last year;

  • 40% of psychiatrists report physical assault;

  • the rate of workplace violence among psychiatric aides is 69 times higher than the national rate of workplace violence;

  • 61% of home healthcare workers report violence annually; and

  • family physicians are also at high risk, although limited data exist in the outpatient setting.

These statistics, however, may not reflect the full extent of the problem. Statistics vary, and most studies have relied on voluntary retrospective surveys, which are fraught with bias.

Inpatient emergency department and psychiatric wards have been studied most, perhaps because they experience the highest levels of violence. Studies show that nurses and nursing aids are at highest risk, especially those who work in inpatient psychiatric wards.

What contributes to the problem? Most commonly, altered mental status resulting from dementia, delirium, substance abuse, or decompensated mental illness, according to Dr Phillips. Other contributors may include long wait times, crowding, poor food quality, receiving "bad news," low socioeconomic status, gang activity, and patients in police custody.

However, Gordon Gillespie, PhD, associate professor and deputy director of the Occupational Health Nursing Program at the University of Cincinnati in Ohio, disagrees that most incidents involve individuals with altered mental status or mental health patients. Rather, he told Medscape Medical News, this perception is the result of biases in the literature caused by underreporting.

According to his own research, about half of violent incidents involve behavioral health patients, whereas the other half involve patients who have nothing to do with mental health. But those types of encounters are not always reported because of a perceived lower likelihood that the patient will be seen again.

An "Iceberg" Problem

In fact, underreporting represents a major hurdle to tackling the problem. Just 30% of nurses report workplace violence, whereas 26% of physicians do, according to one study. The professional culture of healthcare, which often considers violence as "part of the job," likely contributes.

Underreporting is an "iceberg problem," according to Dr Gillespie.

"You can see the tip of the iceberg, but you can't see everything underneath," he said, "There's so much underreporting that the problem is a lot worse than what the statistics show."

Uncertainty about what actually counts as violence may also play a role, especially in patients without full control of their faculties. Whether the act is intentional or not, it should always be counted as violence, according to Dr Gillespie.

"No violence should be tolerated, ever," he said, "If we made the assumption that all patients or visitors have the potential to become violent, we would interact with them differently, and we would be safer."

Discounting unintentional violence can contribute to underreporting, he explained. Acknowledging and reporting even unintentional violence can help staff identify which patients have been violent in the past and take precautions, such as flagging a patients' chart, to avoid violence when the patient returns.

"The difference between intentional and unintentional are the consequences," Dr Gillespie added, "For the confused older adult, person with low blood sugar, or a child, there's no intent. It won't have a consequence, but you can still do a prevention plan."

No "One-Size-Fits-All" Solution Exists

Although scant research exists about which interventions are effective in reducing levels of workplace violence in healthcare, what is clear is that no "one-size-fits-all" approach exists.

"Every hospital, office, and long-term care facility is unique, and each one needs a multimodal multidisciplinary approach to determine which changes are liable to be successful," Dr Phillips said.

Rather than profiling patients, experts recommend an "all hazards" approach, similar to universal precautions used to avoid bloodborne pathogens. Setting limits and having a zero tolerance policy for violence will help healthcare get away from the current reactive mindset and move toward a more proactive stance, Dr Gillespie explained.

"Every single person who comes in through registration, triage, or wherever should know the expectations that everyone should be safe and free from violence," he emphasized.

Proposed solutions include training in aggression de-escalation and self-defense; installing fences, security cameras, and metal detectors; hiring guards; and banning all firearms from the workplace, except those used by law enforcement. Legislation that makes violence against a healthcare worker a felony or mandates that hospitals have violence prevention plans have also been proposed.

Other areas for improvement include increasing staff levels to reduce crowding and wait times, decreasing worker turnover, enhancing reporting methods, and ensuring the existence of a workplace violence committee that reviews all incidents.

The right kind of administrator support is also important, so that staff members can report incidents without fear of retribution.

"The low-level, minor injuries, the daily threats, assaults, intimidation, and burnout that's associated with working under violent conditions with no recourse is a major problem," Dr Phillips said, "Without acknowledgement from administrators and supervisors that this is a serious issue, we're never going to see any changes."

Dr Gillespie agreed. Studies have suggested that the right kind of supervisor support can protect against violence, and he believes the messaging needs to change.

"When an employee reports an incident, the supervisor should first ask 'Are you OK?' rather than 'What did you do?' or 'What happened?' which can be interpreted as accusatory and make the employee defensive," he explained.

Better-quality prospective studies are also needed to identify interventions that actually result in positive change.

"It would be difficult to expect our administrators to provide the limited funds toward something that may not work," Dr Phillips stressed, "If we're able to encourage researchers to find programs that work, we'll have a better chance of getting our administrators to buy-in and provide budgets that allow us to put those changes into place."

The authors and Dr Gillespie have disclosed no relevant financial relationships.

N Engl J Med. 2016;374:1661-1669. Extract

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