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    Keeping Everyone Safe: Violence Prevention in Hospitals

    Educating hospital staff, faculty, and medical students about violence prevention can increase safety and resilience.


    About a decade ago when Terry Kowalenko, MD, was serving on the executive committee of the Michigan College of Emergency Physicians (MCEP), the organization received a disturbing letter from a physician requesting help. In the letter, the physician said a patient’s mother was stalking him and he was concerned for his and his family’s safety.

    Kowalenko said the letter was a distressing reminder that while health care providers face a greater risk of violence and threats on the job compared with other types of workers, no one was documenting the true scope of the problem. In turn, MCEP decided to conduct its own survey. The results, published in 2005 in Annals of Emergency Medicine, found that of the 171 respondents, more than a quarter had been victims of a work-related physical assault, nearly 75 percent had experienced verbal threats, and 3.5 percent reported being stalked.

     The Occupational Safety and Health Administration (OSHA) reports that between 2002 and 2013, incidents of serious workplace violence (specifically, injuries that required time off from work) were four times more common in health care than in private industry.

    “It was a much bigger problem than we had realized,” said Kowalenko, now chair of emergency medicine at Oakland University William Beaumont School of Medicine in Rochester, Mich. “Students should start learning about this very early on. I think it has to happen before they have direct patient care responsibilities.” In his current position, Kowalenko noted that in 2015 alone, staff at Beaumont Hospital, Royal Oak campus—a clinical teaching site for Oakland University’s medical students—made 2,000 calls to security.

    Many incidents that may be filed under the umbrella of workplace violence do not involve guns or physical harm. There is the intoxicated person in the emergency room who curses the nurse who is helping him. Or an enraged, grief-stricken family member who lashes out at an attending. But verbal abuse is a form of violence, too, that can contribute to burnout and low morale of physicians and staff—a problem that has come to the forefront at academic medical centers who have introduced training in anger management and other strategies to manage aggressive patients.

    Today, Kowalenko is part of an effort to train hospital staff in violence prevention and de-escalation tactics. He also brought the topic of occupational violence to Oakland medical students as part of the school’s lunchtime lecture series. “It’s always packed,” he said. In addition, Kowalenko is working with a group of medical students to design a study on experiences of workplace violence during clerkships.

    Bringing the problem to light  

    An article in the New England Journal of Medicine in April 2016 noted that the next big task in reducing occupational violence in health care is finding interventions that work, since a simple, one-size-fits-all solution is unlikely to be effective. Study author James Phillips, MD, an instructor at Harvard Medical School and attending physician in emergency medicine at Beth Israel Deaconess Medical Center, said he became interested in the issue after the 2015 murder of a doctor inside Brigham and Women’s Hospital.

    “After that happened, I went home and started researching—I was literally astounded by what I found,” he said. “I thought [violence in health care consisted of] isolated incidents, but it’s actually pervasive throughout the field.”

    “We teach about safety with blood-borne pathogens, needles, tuberculosis—this is just one more element [of safety] that we can embed.”

    Gordon Lee Gillespie, PhD, DNP, RN
    University of Cincinnati College of Nursing

    Nationally, the U.S. Department of Labor Occupational Safety and Health Administration (OSHA) reports that between 2002 and 2013, incidents of serious workplace violence (specifically, injuries that required time off from work) were four times more common in health care than in private industry. These injuries were most often the result of hitting, shoving, kicking, and beating by patients.  Further, OSHA noted that the incident rates are “vastly underreported.”

    While OSHA does not have specific standards for workplace violence prevention, a coalition of labor unions formally petitioned the Department of Labor in summer 2016 to promulgate such standards to better protect health care and social service workers.

    Phillips is now part of a multidisciplinary workplace violence committee at Beth Israel Deaconess, which he said is working to establish a universal definition of violence to make reporting such incidents easier for staff. “First we have to identify how bad the problem is, and then we can institute reform and see if it actually works,” he said.

    Preventing violence, promoting resiliency

    Early in his career as an emergency department nurse, Gordon Lee Gillespie, PhD, DNP, RN, said he regularly experienced verbal and physical violence on the job. “It became normal; I never thought much about it.” However, when three of his nursing colleagues tried to sue a patient for assault and a judge threw out the case—citing such violence as part of the job—Gillespie realized that normalizing this type of violence was dangerous.

    Since then, Gillespie, now an associate professor in the University of Cincinnati College of Nursing, has authored a number of studies on workplace violence and is leading a project to identify ways to promote resiliency among emergency department staff who experience occupational violence.

    Beyond the direct risk and impact on health care professionals, violence in the workplace can have a trickle-down effect on patient care. A 2012 Joint Commission report on improving worker and patient safety noted that “victimized nurses experienced decreased self-confidence and competence, potentially influencing the quality of nursing care provided and subsequently patient care outcomes.”

    “This is a patient safety issue,” said Gillespie, noting that nurses typically experience more workplace violence than physicians. “It’s no longer about me and that person; it’s me, that person, and everyone else I take care of.”

    Gillespie also maintained that education about workplace violence should start in the classroom. “This is something that will affect students’ ability to process and be safe at work.… We teach about safety with blood-borne pathogens, needles, tuberculosis—this is just one more element [of safety] that we can embed.”

    Perhaps no U.S. health care system has taken on workplace violence like the Veterans Health Administration (VHA), though. The system began addressing the problem in the late 1970s, said Lynn Van Male, PhD, director of the VHA Workplace Violence Prevention Program and assistant professor of psychology at Oregon Health and Science University School of Medicine. By 2009, the workplace violence program had grown so big, Van Male stepped in as its first national program manager.

    Veterans Health Administration leads the way

    The VHA has standardized its Prevention and Management of Disruptive Behavior program across the entire health system.  Van Male explained that staff are trained to recognize, de-escalate, and moderate threatening behavior according to the type and level of violence they may be exposed to. For example, an employee who is only likely to encounter verbal violence may need de-escalation training, but not physical containment training.

    All VHA employees participate in web-based awareness training, the first level of the program. Additional training is determined by workplace setting, said Van Male, and may include three more levels: observational and verbal skills, personal safety skills, and therapeutic containment skills.

    In addition to employee training, the VHA has put in place systems-based precautions. All VHA hospitals are required to convene a committee chaired by a senior clinician to examine disruptive patient cases. Because the VHA is legally prohibited from barring eligible veterans from care, the committees develop patient-specific plans that ensure disruptive patients can access care while still protecting providers. Disruptive behavior committees can also decide to flag disruptive patients in their electronic records as a warning to providers.

    “Often, before awful violence happens, there are signs that weren’t brought together,” Van Male said about the usefulness of communications across all staff. The challenge now, she continued, is developing metrics to determine just how well the system is managing disruptive incidents.