Workplace violence has always existed, and that's certainly true in healthcare. I have worked in healthcare for more than 40 years and have experienced it firsthand.
When I worked as a clerk in an emergency department (ED) years ago, I saw a patient making karate moves. He jumped over the counter, put his fist through the time clock, and then pushed his way deeper into the ED. A highway patrolman drew his weapon, and one of the doctors and I jumped on the patient to get him under control. The doctor gave him a shot of sedative. Later when I was a hospital security officer, a patient I tried to restrain pulled out a piece of broken medical equipment and stabbed me in the arm.
Workplace violence in healthcare is not new, but it is so frequent now that it has reached epidemic proportions. We all heard about the two nurses and a doctor who were stabbed at Encino Hospital Medical Center in California, and the two doctors and two others who were fatally shot at Saint Francis Hospital in Tulsa, Oklahoma. Both incidents happened in the same week in June, and both are examples of a trend. Nationwide, 70% of those who experience trauma from workplace violence are employed in healthcare or related fields (Bureau of Labor Statistics, 2018); more than 40% of nurses report being physically assaulted and 68% report verbal abuse (Byon et al., 2021). Another survey reports that 55% of emergency physicians say that they have been physically assaulted at work (American College of Emergency Physicians, 2022).
Incidents of workplace violence at Scripps Health, where I serve as president and CEO, rose from 1,314 in fiscal year 2020 to 1,808 (annualized) in fiscal year 2022. And our numbers may have been underreported, as they are in healthcare nationally (Byon et al., 2021), for a variety of reasons—not the least of which is that employees have come to consider workplace violence “part of the job.” What's more, there has been an increase in the severity of the attacks we're seeing.
One example that haunts me is that of Mary, a Scripps Health operations supervisor, who was attacked by a patient who threw a chair at her, viciously bit her, and pulled out her hair. Mary was physically and mentally traumatized, but she found the strength to testify at a state public safety committee hearing where a bill that would have increased penalties for violence against healthcare workers was being discussed. Mary came back to work in another capacity, but even with her strength restored, she ultimately decided to leave healthcare. That incident affected not only Mary but also those who worked for her and with her, many of whom sought help through our employee assistance program (EAP). This type of violence has a long reach.
Healthcare professionals are feeling more unsafe now than probably at any time before. Physicians are saying that they have never had patients more dissatisfied and angry, and that they have never been more unhappy as a doctor. Nurses are saying the same thing. We're hearing similar stories from our call centers, too. The uneasiness permeates every part of the organization.
WHY IS THIS HAPPENING?
Patients with behavioral health issues and those who are homeless make up an important part of the healthcare violence equation. Those struggling with mental health issues, the stress of homelessness, or both are much more likely to be unable to cope. And, as mentioned earlier, those assaults are underreported. In a survey of ED nurses, 76% said that their decision to report would be based on whether the patient was perceived as being responsible for their actions (National Advisory Council on Nurse Education and Practice, 2007). We need places for these patients to go for treatment. The lack of behavioral health is a crisis in the United States, and homelessness is not getting any better. Hospitals are bearing the brunt of these forces.
Add to this situation the impact of COVID-19. The pandemic has caused emotional distress for many reasons, including financial loss, childcare issues, and being quarantined from loved ones. Those are among the stressors that affect many people—including patients—beyond being ill. COVID-19 has also caused the civility of public discourse in this country (which had already deteriorated) to become even worse. What should be a public health issue has become a political issue, and the way people talk to each other with ugliness and anger has gotten worse. The stress has risen to the point where the violence switch is more easily triggered. For patients struggling with mental illness, drug addiction, and homelessness, that trigger is especially sensitive. They lash out at the people who are trying to help them.
People in healthcare don't feel safe. They feel abused. They feel burned out.
PROTECTING OUR WORKFORCE
So, what can we as healthcare leaders do to protect our workforce, now and in the future? At Scripps Health, we are taking several approaches to improve the situation.
We think of our people first. We support those who are hurt on the job and those who are struggling. We encourage staff to get help for themselves sooner. We have seen a lot of employees coming into our EAP later than they should, so their acuity level is higher than we have seen in the past. After trying to tough it out for too long, they finally come in when their lives are falling apart. We want them to know that it's OK to get help; it's OK to take a break if they need a break. We'd rather they do that than wait too long and feel the need to leave healthcare altogether.
We do a lot of organizational development work with our people to try to normalize what they are going through and give them tools to deal with an angrier public. Part of this is our new de-escalation training. We reached thousands of employees with this training in just its first few weeks. The training includes a video and a tip sheet that are available online, and we are offering continuing medical education credits to encourage even more participation. The de-escalation training starts with one of our CMOs sharing case scenarios. Then I talk about my experiences as a former police officer. A staff psychologist with our EAP discusses the reasons people behave the way they do and describes ways to handle them that will de-escalate the situation rather than make it worse. Our head of security offers practical techniques about how to stay safe in healthcare settings.
Awareness is one of the main focal points of our AVADE (Awareness–Vigilance–Avoidance–Defense–Escape) violence prevention program, as well. The first part of AVADE training covers how to keep people from becoming physically violent. The second part includes tools and techniques that employees can use to protect themselves if a patient does become physically violent. The third part covers what security officers should do when they have to detain or escort somebody.
Beyond training, we also provide vital resources and make procedural changes to make staff feel safer and, ideally, be safer. The following points cover some of the measures we are taking.
- To help staff prepare for their work with patients who have a known history of violence, the patients' identification bracelets are purple and their rooms are marked by a peace sign on the door.
- We ensure that we have the best security team possible through competitive hiring and retention practices, and we arm our officers with Tasers. I don't support arming with guns because there is too great a chance that someone else can grab a gun during a tense situation and cause serious injuries or death. Tasers have proven to be an effective visual assault deterrent and de-escalation tool.
- We are implementing a metal detection station at the ED entrance of our hospital where the highest number of workplace violence incidents occur. The station is equipped with advanced technology to screen personal belongings. Some 75% of inpatient admissions come through the ED, so, if we address security concerns on the front end, we can then make the inpatient units safer.
- Also at this hospital, we are closing the lobby from 8 p.m. to 5 a.m. An intercom system enables access for people who come to the front entrance when it is closed. For the employee and freight elevator banks that open directly onto patient care units, we are installing systems that require badge access.
Many of the recent improvements described here are the results of input we received from staff, which we continue to solicit through regular town halls, unit-based committees, daily huddles on the units, workplace violence prevention committees, and executive and senior team rounding. We have established open lines of communication between unit and executive leadership levels through e-mail, phone, text, and personal conversations. But reducing workplace violence in healthcare requires a wider effort. Accordingly, we have reached out to law enforcement to engage with them and improve safety measures for patients who are brought in as prisoners.
SHARING THE RESPONSIBILITY
Patients themselves need to take some responsibility for the safety of the healthcare workforce. At the beginning of the pandemic, we were their heroes, with tributes and gifts coming in regularly. But as things wore on, we went from heroes to zeroes, with the accompanying verbal and physical abuse. We include messaging in our e-mail, social media, and other communications channels to bring patients' attention to their role in addressing workforce violence. We urge them to be kind to our staff as they work hard to help their patients. Beyond the “be kind” messaging, signage throughout our facilities lets patients know that abuse of our staff will not be tolerated.
Of course, holding people responsible for acting civilly as patients must go beyond messaging and signage. The assault of a healthcare worker should be a serious crime, yet in California, it's not. We have tried unsuccessfully to get this changed, although there has been some movement on the national level. In June, federal legislation was introduced in Congress (Safety from Violence for Healthcare Employees, 2022). The bipartisan bill includes protections similar to those that exist for flight crews that would make it a federal crime to assault a healthcare worker—with severe penalties attached. Until meaningful support such as this is in place, we as healthcare leaders must keep trying to do all that we can to protect our own. Danger to healthcare workers is a danger to all those who depend on us to care for them when they are at their most vulnerable. We can't continue to help those who are hurt if we are being hurt ourselves.
Bureau of Labor Statistics. (2018). Table R4: Number of nonfatal occupational injuries and illnesses involving days away from work by industry and selected events or exposures leading to injury or illness, private industry, 2019. https://www.bls.gov/iif/oshwc/osh/case/cd_r4_2019.htm
Byon H. D., Sagherian K., Kim Y., Lipscomb J., Crandall M., Steege L. (2021). Nurses' experience with Type II workplace violence and underreporting during the COVID-19 pandemic. Workplace Health & Safety, 70(9), 412–420. https://doi.org/10.1177/21650799211031233
National Advisory Council on Nurse Education and Practice. (2007). Violence against nurses: An assessment of the causes and impacts of violence in nursing education and practice. https://www.hrsa.gov/sites/default/files/hrsa/advisory-committees/nursing/reports/2007-fifthreport.pdf
Safety from Violence for Healthcare Employees Act. (2022). H.R. 7961. 117th Cong. https://www.congress.gov/bill/117th-congress/house-bill/7961/text?r=179&s=1