Healthcare's epidemic of workplace violence: 5 top safety challenges and 6 best practices to minimize harm

Serious workplace violent incidents are four times more likely to occur in healthcare environments than in private industry. In fact, healthcare accounts for nearly as many serious violent injuries as all other industries combined, according to the Occupational Safety and Health Administration. Healthcare professionals in certain sectors of the industry are even more vulnerable to workplace violence than law-enforcement officers and security guards.

Take Stanford Hospital in Palo Alto, Calif., for example. A series of lapses in security and protocol in the hospital's psych unit on March 12, 2019, left 70-year-old Catherine Kennedy, RN,  vulnerable to a patient attack that shattered her knee and fractured her leg. She was punched more than 20 times before security could intervene. Unfortunately, Ms. Kennedy's case was not an anomaly. On a national scale, about 1 in 4 nurses have been assaulted, according to the American Nurses Association. Between 2011-16, 58 hospital workers died from physical violence they encountered on the job.

"Workplace violence is all too common of an event happening in hospitals today, and we are deeply troubled by it," said Brent Lang, president and CEO of Vocera Communications, during a sponsored breakout session about safety on Nov. 12 at the Becker's Hospital Review 8th Annual CEO + CFO Roundtable in Chicago. "For caregivers to have to worry about being attacked by visitors, patients or patient family members is unacceptable," he said.

When Mr. Lang asked the room of 20 hospital and health system executives how many of them had faced staff safety issues at their organizations, almost every hand went up. "There is a duty and a responsibility for all of us to think about the ways we can either prevent, respond or react more effectively to make sure we are taking care of our most valuable assets — our employees and teams," he said.

The discussion led by Mr. Lang touched on Ms. Kennedy's attack at Stanford and other similar incidents, as well as the practices, processes and technologies hospitals are using to respond to and prevent these threats. What follows is an overview of the five most common safety challenges discussed at the roundtable, followed by interventions hospitals are using today to address this critical issue.

5 common safety challenges for patients and staff

1. Physical abuse. Physical abuse, most often inflicted on staff members by patients or visitors, was a common challenge cited by executives in the room. "I've seen people tackled to the floor," said the CEO of a hospital in the Midwest. He told the story of an inebriated patient who came to the emergency room after a car accident and attacked staff members. Difficult patient populations, such as patients under the influence of drugs or alcohol, people with psychiatric needs or elderly people with dementia, are often involved in such incidents, according to the executives present. "We're finding that the patient population with dementia or delirium is now the one causing most staff injuries," said a nurse director from a midsize hospital on the East Coast.

2. Verbal abuse. Another common form of violence faced by hospital workers are threats, intimidation and verbal abuse. When asked how the opioid epidemic affected hospital work environments, an executive from a major West Coast health system noted an uptick in threats from patients seeking painkillers. "We find that patients come in and they feel they're entitled to that medication and if you don't provide it, then they get verbally abusive," he said. 

3. Gun violence. The CNO of an academic medical center in New York shared an incident when an active shooter walked into the emergency room at her organization. She recounted: "The patient walked into the ER, and the triage nurse said, 'How can I help you?' And he said, 'I'm here to shoot you,' and pulled out a gun," she said. Active shooter threats, as well as patients armed with weapons, were common at the organizations represented in the room.

4. Communication breakdowns. A more insidious threat discussed by executives was a failure in communication, either between teams at the hospital or with external collaborators like police. The CNO of a chain of freestanding emergency centers recounted a Code Silver that occurred in one of the EDs in his system. In the medical setting, this means someone has a weapon. Police happened to be onsite, but they didn't act on the code right away. To the officers, a Code Silver meant an elderly person was lost. "They didn't realize that there was actually an incident happening," he said.

5. Chaos and disorder. Crowding, noise and alarms can contribute to chaos and disorder, which can aggravate vulnerable patients or create an environment where mistakes are likely to occur. The night Ms. Kennedy was attacked at Stanford Hospital, a shift change occurred during visitors' hours, so a lot of people were in the unit at the same time. A state report of the incident noted that the unit was "chaotic and disorganized." 

"Many of you have made reference to this cacophony of alerts and alarms that are coming through to our care providers that are just really overwhelming," Mr. Lang said. "Providers don't really even have the ability to respond to one alarm because the next alarm is already going off."

6 best practices to improve staff and patient safety

The executives also discussed the ways their organizations dealt with these challenges. Here are six best practices that emerged from the roundtable:

1. Extra layers of security. Many executives in the room said their facilities were either equipped with metal detectors, additional security cameras or hired uniformed police officers. A few executives worked at organizations that had taken extra steps to make these measures even more secure. One CNO said uniformed police officers and undercover detectives in scrubs patrol the hallways of the urban academic medical center where she works. "That made staff feel unbelievably secure," she said. Another nurse director said her hospital uses metal detectors in the lobby, but as an extra measure of security, now works with emergency medical services (EMS) teams to ensure patients are screened for weapons before they even set foot on the hospital campus. "On a daily basis, we secure weapons from people coming in, either through the lobby or through our EMS system," she said.  

2. Improved patient flow. A nurse director from a midsize hospital on the East Coast said the high-volume ED at her hospital regularly experienced overcrowding to the point where staff had to ward behavioral health patients in hallways. To reduce the chaos, her hospital began prioritizing behavioral health patients in the ED. "We totally changed our process for the care of behavioral health patients, and we also embedded security into the department because nursing staff were so fearful," she said. "Rather than having those patients be in the queue and not prioritized, they're prioritized up front and they're cared for by a provider immediately."

3. Panic buttons. The CNO of a public hospital said her organization puts panic alarm buttons linked to police responders under desks or on computers, while another CNO said her organization puts panic buttons on staff ID badges.

Nurses use the panic call feature on the Vocera Badge almost once per week, according to Mr. Lang. The critical need for this type of communication led the company to redesign this feature on the Vocera Smartbadge. This new wearable communication device has a dedicated panic button that opens up a live voice channel to a predefined response team. That team can hear audio and determine the staff member's location. "It's almost like a stealth button in the background," he said. "The idea is that, rather than having to get to a call button on the wall or under a table, nurses have access to help immediately on their body." 

4. Plain language. The CNO whose freestanding ED had experienced the Code Silver misunderstanding told the group his organization is switching over to Plain Language, an initiative across departments to use literal terminology for broadcasting codes. "The concern is obviously if you're saying, 'Person with a weapon,' and people hear that, it would create panic. But that also creates eyes and people that are aware," he said. "I think better coordination and communication among the departments, police, EMS and everyone else is important."

5. Reduced noise. "Things like reducing the noise level, which brings the overall level of stress in the hospital environment down, can actually help cause fewer attacks," Mr. Lang said. This may be achieved by reducing unnecessary activities at night or reducing unnecessary alarms and overhead pages. "Patients notice the difference, and they really need a quiet environment to heal," Mr. Lang said. In addition to soothing patients, less noise can also reduce cognitive overload for staff, making it easier to focus and do their jobs.

6. Resilience and well-being initiatives. Many executives shared strategies for keeping staff resilient, happy and satisfied as a way to improve workplace safety. "A lot of hospital initiatives that start with quality or start with patient experience or start with changing operational throughput issues fall flat. And they fall flat because in many cases the care providers are not included in that thought process, in the design of the solution or in the philosophy," Mr. Lang said. For example, a chief quality officer shared that her medical center in the Pacific Northwest uses resilience training to help improve the mental and emotional well-being of employees. The program is focused around building resilience to stressors identified by heart rate monitors. "Assumptions about what caused them [employees] stress were not always accurate," she said.  

The CNO of an urban academic medical center said her hospital implemented a Code Lavender program, a formalized rapid response designed to support patients, families, nurses, physicians, and staff members in times of emotional distress. The code can be broadcast after a significant incident occurs that emotionally affects staff, such as a medication error that results in patient harm. When calling a "Code Lavender" at this organization, a group of social workers, psychiatrists and the medical team will respond. "It really serves to offer tremendous support to the staff," she said.

Safer staff means safer patients

Nurses and frontline providers understand that their job comes with a measure of inherent risk, but the current rate of violence against nurses has reached proportions described by some industry leaders as an "epidemic." The rates of violence paired with the increasing threats posed by active shooters demand action from hospital leaders. Protecting staff is enough reason to take action, and keeping staff safer will translate into added benefits for patients. When clinicians feel safe, they're better empowered to deliver quality, safe care to vulnerable patients. 

"As an organization, our mission is really about improving safety and the lives of patients, families and healthcare professionals," Mr. Lang said about Vocera. "We focus on staff well-being, resiliency and satisfaction, which has a direct impact on patient experience, cost savings, and quality outcomes."

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