The headline-making events are familiar and chilling: a Boston cardiologist murdered in a hospital by the son of a deceased patient; an Indiana physician shot for refusing to prescribe opioids to the killer's wife; a Texas surgeon shot and killed while riding his bicycle, the act perpetrated by a man nursing a 20-year grudge over the care his family member received. These events are thankfully rare but, for the many medical providers across the country who experience intimidation or overt verbal and physical violence, the threat of workplace violence exacts an immense toll.
Despite these extreme examples, violence against health-care providers is underreported, understudied, and undertreated. Data collection is inconsistent and spotty, making it difficult to find effective strategies for preventing and managing outbreaks of violence.
"In my experience, this problem is getting worse, but I can only speculate because there aren't good data about violence in the health-care workplace," said James P. Phillips, MD, from the George Washington University Hospital in Washington, DC. As an emergency medicine specialist, Dr. Phillips is on the "front line" of workplace violence but, he said "with no universal system for defining the issue, there is no way to definitively say if it's getting worse, better, or staying the same."
Part of the issue is that violence against health-care workers is so common, it's become normative. Among victims of violence in medical settings, only 30 percent of nurses and 26 percent of physicians reported the incidents (SIDEBAR 1).
“We need to change the employee's mindset from â€˜violence is a part of the job' to â€˜violence is a problem that needs to be managed,'" said Judy Arnetz, PhD, in a webinar sponsored by the Occupational Safety and Health Administration (OSHA) and the Joint Commission.2 Dr. Arnetz researches violence in health-care settings at Michigan State University.
The first step toward that goal, she believes, is to improve reporting. "If you don't have any data, there simply is no problem! The data are your evidence."
ASH Clinical News spoke with Dr. Phillips, Dr. Arnetz, other health-care practitioners, labor lawyers, and security specialists about the prevalence and causes of workplace violence.
An Expansive, Expensive Problem
Workers in the medical field, compared with other workplace settings, are particularly vulnerable to violence. According to data collected by the U.S. Bureau of Labor Statistics about the incidence of intentional injury by other people, the health-care and social assistance industry had the highest rate of nonfatal injury cases of any industry in 2014, at 8.2 cases per 10,000 full-time workers and more than 11,000 injuries.3
In 2013, 27 out of the 100 fatalities in health-care and social service settings that occurred were due to assaults and violent acts.4
These data are corroborated by a 2011 National Crime Victimization Survey, which estimated that between 1993 and 2009, health-care workers had a 20-percent higher rate of workplace violence than the average seen by all workers.5 Workers in certain sectors of the health-care industry are more vulnerable to these attacks – for example, for those working in mental health-care settings, their experience of workplace violence rivals that of law-enforcement officers, security guards, and bartenders.
As a consequence, the health-care sector spends billions of dollars related to managing workplace violence. A 2017 report prepared for the American Hospital Association estimated that workplace violence cost U.S. hospital and health systems approximately $2.7 billion in 2016, including $280 million related to preparedness and prevention, $852 million in unreimbursed medical care for victims, $1.1 billion in security and training costs, and an additional $429 million in medical care, staffing, indemnity, and other costs related to violence against hospital employees.6
Further, health workers who were victims of violence experienced an average of 112.8 hours per year of sick, disability, and leave time (excluding long- and short-term disability), which was 60.4 hours more per year than counterparts who had not experienced workplace violence.
In certain health-care settings, workers are more vulnerable to violence; still, no setting is completely safe.
According to the "Guidelines for Preventing Workplace Violence for Healthcare and Social Service Workers" published by OSHA, "While no specific diagnosis or type of patient predicts future violence, epidemiological studies consistently demonstrate that inpatient and acute psychiatric services, geriatric long-term care settings, high-volume urban emergency departments, and residential and day social services present the highest risks."4
Organizational factors that contribute to a higher risk of violent incidents include: high worker turnover; inadequate security and mental health personnel on site; and lack of policies and staff training for recognizing and managing escalating hostile and assaultive behaviors from patients, clients, visitors, or staff.
"The most intentional violence we see in the emergency department seems to come from people who are intoxicated," Dr. Phillips noted. One might think that a strong security presence in the emergency department would solve the problem, but according to Dr. Phillips, police and security guards can only offer so much assistance.
"In my career, I have never seen a patient arrested in the emergency department," he said. "I have had one patient convicted of felony assault against me and had another patient [against whom] I should have pressed charges for felony assault against me." In the second incident, the patient was being restrained by police and intentionally spit hepatitis C–positive blood into Dr. Phillips's face.
"Just two weeks ago, a patient threw a full can of Coke at my head," he added. "Two psychiatric patients were arguing with each other in the hallway and, when I stepped in to intervene, a full can of Coke – thrown by the patient behind me – brushed past my ear."
Even if police witnessed the event, he said, there was little to do about it. "I told the patient not to do that again or I'd have her arrested, but she was a psychiatric patient there under an involuntary hold who was going to be placed into a psychiatric facility. She wasn't some I could actually have arrested."
Patients with diminished mental states also often lash out in acute-care environments, Dr. Phillips noted. "Being in an unfamiliar environment, or being touched by unfamiliar people, can make people with Alzheimer disease or dementia agitated. Often they don't intend to cause harm, but they'll act out of secondary fear."
Patients on the Edge
"Violence occurs on all types of units," said Dr. Arnetz. "We know that doctors and nurses in the emergency department and psychiatric units or any unit that sees many elderly patients who may have cognitive issues, have greater risks for being the victims of violence, but, to be honest, no one is at low risk."
The OSHA guidelines continue: "Pain, devastating prognoses, unfamiliar surroundings, mind- and mood-altering medications and drugs, and disease progression can also cause agitation and violent behaviors." In other words, what many patients encounter when visiting a hospital or clinic.
"Other than for the delivery of a child or a check-up, people are visiting a health-care provider because things aren't going well," Ralph Nerette, the director of security at Dana-Farber Cancer Institute in Boston, told ASH Clinical News. "They usually are coming here with stressors beyond their health issues, so I think it's reasonable to expect an increase in incidents of conflict in these settings compared with other workplaces.
"When we have to deliver bad news to a family, there is a lot of emotion involved, and there are many examples of medical providers who have been the target of that emotion," he added. This is such a well-recognized aspect of being a health-care provider, "that we teach people about where to stand and how to ensure access to the door should you need to get out of a room."
Although hematologists spend little time on the front line of health-care violence, they also report challenges dealing with threatening patients. Earlier this year, ASH Clinical News Associate Editor Alice Ma, MD, recounted an unnerving experience with a patient with hemophilia and a long list of grievances that were voiced aggressively enough that Dr. Ma's staff felt she needed to be protected ("Not What I Signed up For," March 2018).
"We need to change
â€˜violence is a part of
the job' to â€˜violence is
a problem that needs
to be managed.'"
â€”Judy Arnetz, PhD
"The patient was upset about the copay for his monthly narcotics, the winter weather, the poor heat and insulation in his girlfriend's apartment, his unemployment, and his lack of disability insurance – for which he apparently blames me," she wrote. "He also has an anger management issue and depression, and he's been fired from work for assaulting people who â€˜got in his face.'"
With the assistance of center staff and security – and a plan to transition the patient to another hemophilia center – the situation resolved without violence.
Readers responded to Dr. Ma's article with their own experiences treating potentially violent patients, shining a light on the emotional toll that it can take on patients and providers.
"[The psychosocial components of patients' lives] greatly impact their clinical care. Each patient is dealing with poverty, depression, poor coping mechanisms, lack of social support, perpetual stigmatization, and undiagnosed or mismanaged neurocognitive deficits," wrote Laura M. De Castro, MD, a sickle cell disease specialist from the University of Pittsburgh Medical Center. "What really keeps me up at night is the reality that, while we are providing the best and most comprehensive medical care for these unfortunate patients, some people feel that their needs are unmet, even when multidisciplinary teams are available at most outpatient clinics. We the providers (including the care managers, social workers, pain specialists, and psychiatrists on these teams) can sometimes feel impotent to help them."
"While I, too, have experienced a small share of threatening situations from patient families, I have found that, in most instances, the best defense is not a strong offense," wrote Sidharth Mahapatra, MD, PhD, from the University of Nebraska Medical Center. "Rather, true engagement with the individual and a show of sincerity have gone further than defensive tactics."
Under-Regulated and Overlooked?
In addition to being understudied, violence in health-care workplaces also is underregulated. The OSHA "Guidelines for Preventing Workplace Violence for Healthcare and Social Service Workers" are just that – guidelines, not rules.4
"The only law that legally binds us to workplace violence prevention is called the General Duty Clause, which goes back to the original U.S. Occupational Safety and Health Act of 1970," Dr. Arnetz explained. The clause states: "Each employer shall furnish to each of his employees employment and a place of employment which are free from recognized hazards that are causing or are likely to cause death or serious physical harm to his employees."7
"OSHA has been trying to push standards under the General Duty Clause, but there is no specific OSHA regulation addressing workplace violence that is an express requirement under the law," said Nathaniel M. Glasser, a health-care labor and employment lawyer at Epstein Becker & Green, P.C., in Washington, DC.
The General Duty Clause is reserved for OSHA inspections that involve a violation for which there are no applicable safety or health standards. To warrant a violation, OSHA inspectors must find that the employer failed to keep the workplace free of a hazard to which its employees were exposed; there also must be a feasible method to correct the hazard. In the health-care setting, when the "hazard" might be a patient with a long-term illness or a mental-health issue, this is easier said than done.
"The fact that there is no national standard for a workplace hazard that is so well-recognized is pretty astonishing," Dr. Arnetz added. "The steps OSHA recommends are commonsense actions, but there should be data behind those recommendations. Yet we don't even have data to know how big the problem really is." (See SIDEBAR 2 for a summary of the OSHA guidelines.)
The OSHA document covers a wide variety of scenarios and includes a vast number of suggestions, including special precautions for health-care workers who function outside institutions and offices. Home-care settings are considered particularly risky; in one survey, 61 percent of female home-care workers reported having experienced at least one type of workplace violence (verbal aggression, workplace aggression or violence, or sexual aggression or violence) in the past year.8
Dr. Phillips stressed the need for better reporting. "As nurses and doctors, we don't record violent events accurately, and it's difficult to compare data from different sites because we're not using universal definitions of workplace violence," he said.
Building a database of these incidents would assist organizations with developing effective preventive strategies and would prevent escalation, he continued. "When verbal abuse and low-level battery are tolerated, more serious forms of violence are invited."1
He hopes clinicians will start to pay more attention to the problem of workplace violence – an issue that has traditionally been taken up by nurses and nursing aides, who are the most common victims of patient and family member violence.9 "Nursing staff have been struggling with this for decades. We're sorry we're late, but we're here now to try to make a difference."
At Dana-Farber Cancer Institute, between 1,100 and 1,500 patients are seen daily in the ambulatory practices – meaning there are many opportunities for conflicts to arise. Mr. Nerette said his team is called on regularly to manage potentially hazardous situations.
"Many of our patients are managing diseases that require prolonged hospital stays or may require multiple visits to the hospital each week," he noted. "As patients and caregivers navigate the continuum of care, they bring external issues with them. And sometimes family members feel the need to advocate on the patient's behalf, but they're doing so from a position of emotion rather than facts or data."
As the saying goes, an ounce of prevention is worth a pound of cure, so Mr. Nerette and his security team try to address aggressive or agitated behavior early – before it escalates to violence.
"My primary concern is the safety of everybody in the environment, specifically our workforce," he said. "When someone shows the inability to behave appropriately in the environment, it compromises our ability to deliver great care."
If inappropriate behavior persists, Mr. Nerette's next step is drawing up a behavioral contract with patients and families, mandating that, for the patient to continue to receive care, he or she will act appropriately.
In recalcitrant or extreme cases, the patient can be asked to seek care elsewhere.
"When people don't feel safe, they don't perform at their best," he continued. "If the patient creates a situation where our providers aren't delivering the best possible care, we could be doing a disservice to the patient by continuing care. Perhaps these situations create an opportunity for the patient to reevaluate his or her circumstances and seek elsewhere care that fits his or her needs."
It is a tough conversation, but not an uncommon one, Mr. Nerette said. "Honestly, we have that conversation at least once or twice a month."
From a legal perspective, added Mr. Glasser, other than in emergency situations, "a physician would be allowed to refrain from treating under circumstances in which a patient becomes violent and the physician does not believe it is safe or appropriate to treat."
"Organizations that understand, prepare for, and are resourced to manage the threat of violence against their employees do better, because even people who are potentially violent require health care," said Mr. Nerette. "It's just a matter of asking ourselves, â€˜How do we deliver that care in a way that's safe for all involved?'"
In 2017, Dr. Arnetz and her group published findings from one of the few randomized, large-scale studies to assess the impact of preventive strategies for violence in the hospital workplace.10 "Our goal was to develop what I called â€˜standardized methods' for the development of violence-prevention plans," she explained. "Any hospital can do this – it doesn't take a lot of money or time."
The study included 41 units across seven U.S. hospitals, 21 of which were randomized into an intervention group. These units were provided with unit-level violence data, along with data from other units for comparison, and a checklist of possible environmental, administrative, and behavioral interventions derived from OSHA guidelines. Control units received no data.
"We then gave them the task of putting together an action plan based on the data they had received," she continued.
The solutions proposed by unit staff were practical, varied, and, for the most part, relatively inexpensive and simple to implement. For example, one inner-city hospital felt better enforcement of visiting hours would be helpful, while another opted to install lockers for patients and visitors because they found that theft was leading to physical violence. Behavioral interventions included active-shooter training and debriefing with all staff at the time of an incident.
Six months after implementation, there was a significant reduction in violent events in the intervention units compared with the control units (incident rate ratio [IRR] = 0.48; 95% CI 0.29-0.80; p<0.01). At two years, the risk for violence-related injury remained lower on the units that developed data-driven interventions (IRR=0.37; 95% CI 0.17-0.83; p<0.01). Also, while the incident rates of violence-related injury increased significantly on control units, rates on intervention units remained stable.
As a labor and employment lawyer representing health-care employers, Mr. Glasser is a strong proponent of prevention plans. "It is particularly important for hospitals and other health-care facilities to be prepared because they are dealing with intimate and often one-on-one relationships between patients and health-care workers," he stressed. "The families also are involved, so there are many people and many interests to account for."
Certain legislators are trying to make prevention a priority on the federal level. In March 2018, U.S. Representative Ro Khanna (D-CA) introduced the Health Care Workplace Violence Prevention Act, which would direct the Secretary of Labor to issue an OSHA rule that requires certain health-care employers, including hospitals, outpatient settings or clinics, psychiatric clinics, rehabilitation hospitals, and long-term care hospitals, to adopt comprehensive violence-prevention plans. Ultimately, this obligation will extend to home health and hospice agencies.
The bill piggybacks on California legislation enacted in 2014 that directs Cal/OSHA to develop workplace violence-prevention plans. The California bill went into effect in 2017 and, by April 1, 2018, all health-care facilities in the state were required to have issued their plans to all employees.
The federal bill has 28 cosponsors (27 Democrats and 1 Republican) but is thought to have little chance of passing through Congress.
"There is a definite tension between what is going on in California – where employers are obligated to establish strategies and mechanisms to ensure worker safety – and the actions on the federal level to secure the rights of patients," Mr. Glasser observed.
The Centers for Medicare and Medicaid Services and the Joint Commission have established regulations regarding the use of restraints or seclusion – strategies that hospitals and clinics might employ to protect their workers or other patients. "It will be interesting to see how these tensions play out in California, in particular," he added.
Despite the efforts of hospital administrators, federal legislators, or individual practitioners, violence in the health-care workplace will never be eliminated completely, but the experts who spoke with ASH Clinical News agreed that it is time to act far more decisively against the issue and make conscientious and focused attempts to reduce its frequency and impact. â€”By Debra L. Beck
- Phillips JP. Workplace violence against health care workers in the United States. N Engl J Med. 2016;374:1661-9.
- The Joint Commission. "Workplace violence prevention: implementing strategies for safer healthcare organizations." Accessed September 29, 2018.
- Federal Register. "Prevention of workplace violence in healthcare and social assistance: a proposed rule by the Occupational Safety and Health Administration." Accessed October 19, 2018.
- Guidelines for preventing workplace violence for healthcare and social service workers. Accessed September 27, 2018.
- S. Department of Justice. Special report: workplace violence, 1993-2009. Accessed September 29, 2018.
- American Hospital Association. Cost of community violence to hospitals and health systems, July 26, 2017. Accessed September 27, 2018.
- OSH Act of 1970, SEC. 5. Duties. Accessed October 20, 2018.
- Hanson GC, Perrin NA, Moss H, et al. Workplace violence against homecare workers and its relationship with workers health outcomes: a cross-sectional study. BMC Public Health. 2015;15:11.
- Gomaa AE, Tapp LC, Luckhaupt SE, et al. Occupational traumatic injuries among workers in health care facilities â€” United States, 2012–2014. MMWR Morb Mortal Wkly Rep. 2015;64:405-10.
- Arnetz JE, Hamblin L, Russell J, et al. Preventing patient-to-worker violence in hospitals: -outcome of a randomized controlled intervention. J Occup Environ Med. 2017;59:18-27.
The U.S. Department of Labor's Occupational Safety and Health Administration offers the following recommendations for hospitals, long-term care facilities, community care settings, and field workers in crafting their violence-prevention programs.
Management commitment and employee participation: Acknowledge the value of and allocate appropriate authority and resources to establish a safe and healthful, violence-free workplace.
Worksite analysis: Perform a step-by-step assessment of the workplace (with workers and employers) to find existing or potential hazards that may lead to incidents of workplace violence.
Hazard prevention and control: Identify and evaluate control options for workplace hazards, then select feasible controls to eliminate or reduce hazards, with continued follow-up to evaluate their effectiveness.
Safety and health training: Educate all staff members about potential hazards and how to protect themselves and their coworkers through established policies and procedures.
Record keeping and program evaluation: Maintain accurate records of injuries, illnesses, incidents, assaults, hazards, corrective actions, patient histories, and training to determine the prevention plan's overall effectiveness.
Source: OSHA. Guidelines for preventing workplace violence for healthcare and social service workers. Accessed September 27, 2018.