The key to mitigating workplace violence is treating violence as a symptom, not a sickness

Every doc, every healthcare provider has at least one version of the same story—“I was trying to help them and they hurt me!”

I often think about what happened 10 years ago in a busy New York City emergency department. I was an intern and trying to figure out what was going on with an elderly patient with dementia—she was over 80 years old, all sinew and bones, and weighed less than the stuff in my white coat pockets. She couldn’t tell me why she was uncomfortable, but it was clear that she was, writhing in the hospital bed and grunting loudly. Aspiration Pneumonia? UTI? We needed blood from her to figure it out and we tried to settle her down to get it.

Despite her small size it ultimately took four of us and chemical restraints to make any progress—the latter only used after she drew blood with her fingernails from all of us (yes, we savored the irony).

I was shocked by how intense the encounter was and how dangerous—even with a weaker patient—it felt, but I was the only one. The more experienced nursing staff laughed it off and shared all the times where “real” risk occurred and staff (and patients) got hurt.

It’s important to note that these patients never wanted anyone to get hurt—if they remembered the incident, they would often later apologize, explaining the stress they were under, the pain they were in, and the frustration they were feeling. But the incidents had still happened, and continue to happen, with frontline medical staff across the country really getting hurt.

By the way, the elderly woman I tried to care for in the first paragraph? She was having a heart attack. She needed help, and I wanted to help her—how could we make this safer for us both?

A commitment to care
As healthcare providers, we have a desire and responsibility to care for those who need our help. While medical schools may no longer require physicians to take the Hippocratic Oath, modern versions have been penned which refer not only to the importance of treating patients according to laws of science, but suggest that “warmth, sympathy, and understanding may outweigh the surgeon’s knife or the chemist’s drug.”1

You see this every day in what is often called the “front porch” to healthcare, the emergency department (ED). With an emphasis on empathy, and recognizing that many feel they have nowhere else to go, the ED doors are open to all those who enter regardless of hour, condition, race, or socio-economic background. While this creates unique challenges in providing treatment for patients who may be better served by a visit to a primary care physician, or patients who will ultimately be unable to pay for services rendered—this commitment to care can become especially challenging when faced with treating someone who presents at the ED during a violent episode, or when a patient becomes violent or aggressive during their ED visit.

There is no easy answer to finding a balance between offering patients the help that they need and protecting the individual safety of staff and other patients, but identifying and addressing potentially violent behavior early-on during a visit can help more providers care for these patients without incident.

Identifying the catalyst behind the violence
Much of the discussion today on workplace violence focuses on the violence itself. Increasing security at hospitals, drafting behavioral contracts, and even teaching hospital staff de-escalation and self-defense techniques—while effective—all focus almost exclusively on the violence itself instead of evaluating the causes behind that violence and preventing it before it happens. We’re treating the symptom, not the sickness.

When I was working as the chief medical information officer at a large health system in the northwest, in the wake of the Affordable Care Act we saw emergency department visits increase in almost all our hospitals. With larger patient volumes we risked longer wait times and more chaos, both of which can cause patients to become angry or upset—one source of violence. Doing whatever we could do to improve patient experience by streamlining physician workflow and reducing redundancies in care meant that more patients were seen more quickly, avoiding triggers for aggressive behavior.

But other triggers that push at-risk violent patients to become aggressive are harder to see. Of the patients that came into the ED and reacted violently, many also struggled with a substance use disorder, mental health condition, homelessness—or all three. If we could identify that a patient struggled with any condition that might put him or her at risk for a violent episode, we were able to modify the patient’s hospital experience in such a way that would minimize unnecessary stress that could trigger a negative response. These modifications might include treating the patient in a different location, away from the hustle and bustle of the ED, or providing an additional staff member in the room for support to both patient and provider.

By looking beyond the violence we are able to see the reasons behind it, and with the right support we’re able to approach these patients with the “warmth, sympathy, and understanding” fitting of a modern physician.

The importance of collaboration in preventing workplace violence
Although efforts have been made to improve the reporting rates of workplace violence in the ED, it is still estimated that 70% of violent incidents go unreported by nurses, and 74% go unreported by physicians.

That has to change.

Many take to heart George Santayana’s famous adage that “those who cannot remember the past are condemned to repeat it,” but of course it’s impossible for us to learn about a patient’s history unless that history has been recorded. The rise of technology and cross-collaboration of electronic health records (EHRs) have made it easier than ever for hospital staff and physicians to be “in the know” when it comes to which patients have a history of violence. No time should be wasted by spelunking in the EHR—the technology exists to have alerts delivered right to a physician email, hospital fax, or security officer’s cell phone the moment a patient presents who could pose a threat. But these platforms are only as helpful as the information stored, which means we need to create a culture of reporting.

When we feel too busy to report violence, or we fear retaliation, we not only disservice ourselves by keeping quiet—we put those around us, our coworkers and other patients, at risk for the same things we experienced. Understanding that reporting violence is a collaborative effort to reduce future harm is necessary to overcoming the inertia that often exists today and leaves most incidents unrecorded.

Collaboration, however, expands beyond the silos of security alerts. When physicians are able to collaborate with other providers to see a more complete picture of the patient—to get deeper insight into a patient’s underlying substance use disorder, mental health illness, or past trauma—potential triggers for dangerous behavior for the patient and the doc are uncovered, and we can start to address the wounds behind the pain.

And just as those insights into a patient’s disease state(s) often come from outside the ED, the right approach to help them is often found outside the ED. This may mean reaching out to a neighboring medication assisted treatment (MAT) facility to schedule a transition into an appropriate rehabilitation program or calling the patient’s therapist to inform them of the incident for appropriate follow-up attention. It could also mean connecting the patient with resources available in the community to help the patient find appropriate food, shelter, or support in addressing homelessness and other social determinants of care.

Establishing lasting change
In identifying and addressing the underlying issues behind violence, we do more than just prevent another incident. We help start a patient on the road for lasting change.

When it comes to the diseases our patients have, we understand that these illnesses do not define the person sitting in front of us on the table. In fact, we seek to treat the disease so that it no longer is a part of that patient’s life. When it comes to workplace violence, rather than rashly reacting to a potential risk, approaching these patients with the same empathy and understanding can help us proactively pave the way for a smooth visit and better patient—and physician—outcomes.

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Ben Zaniello, MD, MPH, is the Chief Medical Officer at Collective Medical, the nation’s most effective network for care collaboration. Dr. Zaniello has worked in care transformation for over a decade, most recently at Providence St. Joseph Health as Chief Medical Information Officer in Population Health.

1Louis Lasagna, Academic Dean of the School of Medicine at Tufts University

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