What an increasingly anxious workforce means for patient care

Whether a school in Uvalde, Texas, or a hospital campus in Tulsa, Okla., a recent series of violent events are constant reminders of the potential for what could unfold on healthcare workers' home campuses. The omnipresent anxiety over gun violence in the workplace — a possibility that increasingly seems more likely — has negative consequences for care delivery and the patient experience.

"There is definitely a level of anxiety going to work in light of recent events in hospitals and schools across the nation," Jordan Frey, MD, a plastic surgeon at Erie County (N.Y.) Medical Center, told Becker's. "These are places we generally think of as safe spaces. To see that safety violated is jarring." 

Workplace violence has routinely been described as a "long-standing issue" in healthcare. National statistics show employees in the industry are five times more likely to experience workplace violence than all other workers. While not a new problem, both the frequency and severity of recent events have magnified the spotlight on violence and its aftermath, leaving it on the minds of healthcare workers daily. Preston Phillips, MD, was one of five people killed in a June 1 shooting inside a medical building on Saint Francis Health System's campus in Tulsa, Okla. Police said the gunman targeted the physician for pain he experienced after undergoing back surgery performed by Dr. Phillips in May. The alleged motive in this case underlines a growing source of anxiety for providers: being targeted for the care they provide. 

Between the COVID-19 pandemic and the rise of violence in healthcare settings, "This has been really the most unusual two and a half years of my career," Nigel Girgrah, MD, chief wellness officer at New Orleans-based Ochsner Health, told Becker's.

Since the pandemic's start, healthcare workers have been operating under what Dr. Girgrah describes as a "heightened level of anxiety," with recent tragedies perpetuating that state of mind. 

Dr. Girgrah puts it simply: "Physicians and healthcare workers can't serve their patients and communities if they're worried about their basic and physiological needs." 

Becker's spoke with five physicians and clinical leaders to better understand the clinical implications of a healthcare workforce that's become increasingly fearful and anxious about workplace violence. 

Heightened burnout and psychological harm

The fear and increased anxiety in light of workplace violence can lead to increased burnout and psychological harm for clinicians industrywide. 

A study of nearly 3,000 nurses in Canada published Jan. 5, 2021, in Healthcare found that experiencing violence led to adverse mental health outcomes. Nurses exposed indirectly to workplace violence did not report greater mental health problems, but those exposed directly, or both directly and indirectly, were two to four times more likely to report high levels of post-traumatic stress disorder, anxiety, depression and burnout.

This trend is concerning considering the pandemic, coupled with severe staff shortages, have already placed great strain on clinicians over the past two years. Workplace violence is not only contributing to clinicians burnout and complicating retention efforts, but it's also "one reason why hospitals are finding it difficult to recruit staff to care for patients," Gregg Miller, MD, a practicing emergency physician and chief medical officer of Vituity, a practice management and staffing firm, told Becker's.

Ramin Davidoff, MD, is co-CEO of the Permanente Federation, supporting nearly 23,000 physicians who care for 12.6 million members at Kaiser Permanente. He said the effects of psychological injury caused by workplace violence in the industry cannot be underestimated, as it touches clinical staff in many ways, through reduction of staff productivity and other measures. 

"It's something that healthcare organizations really need to pay attention to, helping provide the most secure and safe environments for clinical staff, so that they can be who they are, and they can provide the best possible care for our patients," Dr. Davidoff said.

An erosion of the patient-physician relationship

After an exposure to violence or threats, clinicians experience "less trust and more fear of patients," according to Dr. Miller.

"The personal connection a patient might feel with a healthcare worker is lessened, as in the back of our minds we wonder if this is going to be the next individual who assaults us," Dr. Miller said. "When a patient or family member becomes upset, our first reaction is sometimes 'Do I need to call security to make sure we're safe?' rather than, 'What can I say to help this person feel better?'"

Emergency department visits rose from 94.7 million in 1995 to 142.6 million in 2016, according to an analysis from the American Hospital Association. The rise in demand collides with staff shortages in "almost every" emergency department, Dr. Miller said. "This leads to lower-quality care, with longer wait times and worse patient outcomes," he said. "On a more personal level, when these violent events occur — and they do in every ED — staff morale is strained."

Despite the increasing prevalence of workplace violence, incidents are often not reported. A May 2015 study published in Workplace Health & Safety found 88 percent of 15,000 surveyed clinicians at an American health system had not electronically documented instances of violence, and only 45 percent had informally reported an incident to a supervisor. 

Dr. Frey of Erie County Medical Center said the risks of future violence could lead to changes in the way care is delivered. 

"I fear that the clinical implications may be similar to the implications of potential litigations on physicians' practices," Dr. Frey said, referring to some physicians' concerns over malpractice lawsuits. Fear of malpractice was the most commonly cited reason for performing unnecessary medical care among a 2017 survey of more than 2,100 U.S. physicians.

"Risk of future violence or instability could become an almost subconscious factor in determining [the] type of care or caring at all for a patient," Dr. Frey said. 

A threat to care quality 

Magnified levels of burnout and decreased psychological safety among clinicians can pose serious consequences to care quality and patient safety. 

A 2021 study published in the Journal of Research in Nursing found workplace violence and verbal abuse increased nurses' emotional exhaustion, and nurses who reported higher levels of emotional exhaustion also had lower perceptions of patient safety in their organizations. 

The Joint Commission has routinely warned of the effect disrespectful behaviors can have on healthcare teams' performance, with consequences including medical errors and preventable adverse outcomes. 

Several physicians told Becker's their real-world experiences echo these findings. 

"It's difficult for nurses and doctors and other clinical staff to provide high-quality patient care when they're constantly worried about their personal safety, or they're distracted by disruptive patients or family members, or even have been traumatized from fire [or] violent interactions," Dr. Davidoff said. 

Leah Alexander, MD, a pediatrician at PediatricCare Associates in Fair Lawn, N.J., said she's encountered several situations in her 16 years in private practice that required law enforcement intervention. 

"One occasion that elicited the most fear was a father who told me, 'I wish I had a bomb,' and threatened gun violence toward one of my nurses," Dr. Alexander said. In these circumstances, the nurse or physician's top priority is to de-escalate the situation, which means the patient's needs may not be fully addressed, she added.

Fear for staff safety could also lead to increased use of physical restraints on patients, which could be problematic, as research shows Black patients are more likely to be restrained than other patients, according to Dr. Miller.

"So, there is also an equity component that we need to face," he said. 

Healthcare workers are only human

As state and federal lawmakers propose legislation to better protect healthcare workers, hospitals weigh enhanced security measures and healthcare leaders call for gun safety reform, business as usual continues for healthcare workers. But "the concept of being superheroes has to be debunked," Ochsner's Dr. Girgrah said. "The community has to understand that physicians, nurses, [advanced practice providers and] healthcare workers are human. The superhero concept sort of propagates this sort of uneasiness about self-compassion and self-care." 

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