Patient Violence Against Physicians: What You Can Do

Leigh Page

Disclosures

April 30, 2019

In This Article

How Hospitals and Healthcare Organizations Can Help Prevent Violence

To curb violence, clinicians should enact policies that put employees first. This includes putting out a statement condemning violence against workers, training workers to deal with violence, directing middle managers to take violence seriously, changing the physical environment to reduce violence, and making it easy to report violence.

But in most states, employers are not required to do any of this. Only California and Illinois mandate that healthcare employers have comprehensive antiviolence policies, and there are no such laws in the federal level. OSHA has a list of suggestions. The Joint Commission, the accreditor for hospitals, does not require specific antiviolence policies, although it recently issued a sentinel event alert on the topic.[4]

Cooke advises hospitals to have clear rules on violence and make sure everyone knows about them. She cites airports as an example. "People don't get abusive very often in airports, because they know the culture walking in the door," she says.

She tells her clients to put signage about the policy outside the ED and at the main entrance, stating: "We expect all patients, visitors and staff to be respectful and non-disruptive while in our facility."

Butler agrees with this approach. "A very simple statement has huge safety and security benefits the organization," he says.

In addition, 32 states have made it a felony to assault a healthcare worker. But this is not a strong deterrent, says Phillips, who wrote an article on violence against healthcare workers in the New England Journal of Medicine in 2016.[2] "In my experience, people don't stop when they're told they're going to get charged with a felony," he says.

'We Are Watching You'

The most effective deterrent to violence or any other crime, Butler says, is the certainty of being caught. For this reason, many hospitals have long used closed-circuit television in waiting rooms, care and payment stations, and parking lots.

Butler would go one step further and install television monitors showing visitors their images on the monitor. "This says we are recording your actions," he says. OSHA also recommends curved mirrors, placement of nurses' stations to allow visual scanning of areas, and glass panels in doors and walls for better monitoring.

Security personnel walking around the facility also send a message that you are liable to be caught. Phillips favors using off-duty police rather than private security guards. "Off-duty police tend to have more experience than private security officers," he says. "They can wear their police uniforms, which are taken more seriously."

Hospitals seem to be beefing up security. From 2005 to 2018, more Michigan hospitals reported having security personnel performing rounds, security personnel in the ED, armed security officers, and police or sheriff security officers in the ED, according to a recent study.[17]

Training and Reporting

A number of companies provide training programs to healthcare employees on how to deal with aggressive behavior, and these courses are fairly uniform, Cooke says. The content includes strategies to de-escalate a violent situation, safe holding of patients, and self-defense maneuvers such as getting out of a grip, neck-hold, choke, or hair-pull, she says.

While police are trained in use of force, training for healthcare workers emphasizes nonviolent skills, Cooke says. "Use of force induces pain, such as pulling a person's arm up behind their back or putting a knee in the back," she says. "But healthcare workers are prohibited from using these techniques. They are trained in non-violent techniques."

Cooke recommends that employers encourage reporting of violent incidents and using the resultant data to understand patterns of violence and adjust policies accordingly. However, it has been estimated that only 20% of disruptive and violent incidents are reported.[18]

Cooke says that many of the unreported incidents appear to be low-level violence, including verbal abuse, but they are still important to report, because they could provide a clearer understanding of how violence plays out in a large organization.

The low reporting level could be attributable to a lack of clear directives on what should be reported, lack of time, or lack of interest in reporting on the part of victims or their supervisors. "We need to make it easy for people to report, such as simply logging on a website or calling in and leaving a message," Cooke says. "You wouldn't be asked for a lot of details, but we would get the data."

Other Helpful Steps

Other ways to contain violence include restricting entry to certain areas with a card-access system, installing fences around parking lots, and using metal detectors to look for guns and knives.

Butler reports that more hospitals have been installing walk-through metal detectors. But many hospitals still resist because it might suggest that the hospital has problems with crime, and hospitals would have to hire workers to man the detectors.

Some hospitals install mood music and soft interior colors to calm people down. And when there is a long wait in the ED, staff may be directed to distribute coffee or cookies, and explain why it is taking so long.

The problem, however, is that staff in many EDs often don't have the time to hand out coffee and cookies. This underscores the problem of inadequate staffing, which Battaglia considers the biggest impediment to controlling healthcare violence.  

"The number one condition for aggression in healthcare settings is inadequate staffing—too many patients and not enough staff with eyes on them," he says.

Phillips agrees. "Inadequate staffing means patients are waiting longer and are more likely to get impatient and angry," he says. "It's hard for healthcare workers to offer empathy to patients when they're pressed for time. You can't be empathetic when you don't even have time to take a pee."

Conclusion

Violence against healthcare workers is about more than killings or serious injuries, which are relatively rare. The unnoticed problem in many organizations is the minor acts of violence that occur day-in and day-out and wear people down emotionally. These incidents make health-care workers feel vulnerable and can lead to burnout.

There are many ways to deal with this problem. Healthcare workers can learn to protect themselves from serious violence, and employers can let patients know that even minor acts of violence will not be tolerated.

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