One recent night a nurse at UC Davis Medical Center in Sacramento, California, awakened a patient to provide anti-seizure medication and got a frightening response. The patient “became verbally aggressive” toward the staff, and when the patient’s roommate said, “Don’t be rude to your nurse,” the patient snapped at him, pushed aside the curtain separating their beds, threw something at him, and resumed resisting the staff.
Thus began another assault against health care workers, whom the federal government reports are five times more likely to experience workplace violence than employees in all other industries.
In the past, staff options in such confrontations were typically limited to some form of calming the patient on their own or calling security. In this case, the UC Davis staff called the hospital’s new Behavioral Escalation Support Team (BEST), comprising care providers trained in mental health care and de-escalating conflicts. The BEST staff calmed the patient and, with the nurse present, explained that nurses must visit frequently to check vital signs and well-being. The patient quieted and agreed to cooperate with the nurses.
Calling in de-escalation teams to quell aggressive patients and visitors is one of the strategies that hospitals are employing in response to rising attacks against health care workers.
The Bureau of Labor Statistics reports that the rate of injuries from violent attacks against medical professionals grew by 63% from 2011 to 2018, and hospital safety directors say that aggression against staff escalated as the COVID-19 pandemic intensified in 2020. In a survey this spring by National Nurses United, the nation's largest union of registered nurses, 48% of the more than 2,000 responding nurses reported an increase in workplace violence — more than double the percentage from a year earlier.
The reasons for the aggression vary: patients’ anger and confusion about their medical conditions and care; grief over the decline of hospitalized loved ones; frustration while trying to get attention amid staffing shortages, especially in nursing; delirium and dementia; mental health disorders; political and social issues; and gender and race discrimination. For example:
- A patient who was angry about his continuing pain after a back operation walked into St. Francis Health System in Tulsa, Oklahoma, in June and shot to death the surgeon, another doctor, a receptionist, and a visitor.
- This month, staff at Boston Children’s Hospital were targeted in a harassment campaign through email and social media — including threats of violence — over the hospital’s provision of transgender health care for minors. Boston police launched an investigation into the threats, which included false accusations that the hospital has performed gender-affirming surgery on people under 18.
- A man distraught over the death of his parents at Ochsner Medical Center in Gretna, Louisiana, in January punched unconscious a nurse in the intensive care unit (ICU).
- In a survey of physicians conducted by researchers at four schools of medicine in Chicago, published last year, 23% reported “being personally attacked on social media.” The attacks were primarily about social and political matters (including guns and abortion), race, religion, and patient care.
Aggression has always been a significant problem in emergency departments, yet in recent years hospitals have expanded their prevention and response strategies throughout their facilities.
“I don’t think there is any location [in a medical center] that is untouched,” says Susan Jackiewicz, MHA, MSW, administrator for the Neuroscience Service Line at University of Virginia Health System (UVA Health) in Charlottesville, and co-chair of its Situational Awareness Violent Event (SAVE) initiative.
Responding to increased reports of aggression, the Joint Commission, which accredits hospitals, put new Workplace Violence Prevention Standards into effect in January that focus on identifying security risks, training staff in violence prevention, and collecting information about violent incidents. The standards define “violence” to include aggression that doesn’t involve physical contact, such as bullying, humiliation, and sexual harassment, both in person and electronically.
In Congress, the proposed Safety from Violence for Healthcare Employees Act would increase penalties for assault and intimidation against health care workers, while a budget bill would provide $5 million in grants for health care provider safety and security.
At the same time, hospitals have been taking a plethora of actions, such as training staff, revamping systems and processes, and upgrading technology.
When staffers check in patients and visitors at the Boston Medical Center, the electronic records include “flags” for anyone who has been overly aggressive with staff in the past. That alert gives the staff several options, says Constance Packard, senior director and chief of public safety: maintain a greater distance than usual from the person, be particularly aware of physical or verbal cues of aggression, call security to check someone for drugs or weapons, put extra limits on the visitor’s access, or place the patient in areas of the hospital where staff who specialize in de-escalation are readily available.
Many hospitals use such flagging systems, which help the staff manage a core challenge posed by the minority of patients who turn aggressive: health workers must protect themselves, their colleagues, and all the other patients, while also carrying out their professional, moral, and often legal commitment to care for those who arrive in need of care.
“The staff appreciate getting a heads up” so they can take appropriate steps, says Packard, president elect of the International Association for Healthcare Security and Safety.
Hospitals have also put more restrictions on where visitors can go. A typical example is The Ohio State University Wexner Medical Center, in Columbus, “which used to be like a lot of academic medical centers: wide open, you could come in lots of doors,” notes Elizabeth Seely, MHA, chief administrative officer of the Hospital Division.
In recent years, the medical center has significantly reduced the entrances and hallways where people can go without a staff badge, Seely says. Visitors get logged in with their IDs (such as a driver’s license) and wear stickers that designate where they are allowed to visit.
Also like many other hospitals, Wexner has expanded its security technology, installing more cameras around campus and placing more panic alarms throughout its buildings, as well as providing more personal alarms to staff and equipping all security officers with body cameras and senior officers with tasers.
“If they’re in a situation that’s starting to escalate, they will turn on their body camera and let the patient know,” Seely says. “Knowing that ‘my behavior is being recorded’ is often a deterrent” against further aggression.
The most wide-reaching changes involve strengthening the ability of staff to prepare for and respond to aggression. Ongoing violence prevention training has become routine, often developed by interdisciplinary teams that include administrators and frontline staff from various departments, such as human resources, nursing, security, behavioral medicine, and clinical care.
At Wexner, Seely says, the staff training and planning revolve around such questions as, “What are the signs of escalation — the verbal and the nonverbal cues? What can you do to keep yourself safe? What’s between you and that individual” who’s getting aggressive?
Ideally, violence intervention plans are based on the physical layout, patient mix, and staff concerns in each particular unit, such as the ICU and ambulatory care, says Jane Thomason, industrial hygienist at National Nurses United. She notes that several studies have found that units with plans designed specifically for them experienced significantly lower rates of violence than units without specific plans.
At Wexner, a security specialist “sits with the staff and talks through the risk points in their areas,” Seely says. “What is your means of exit, so you don’t get yourself backed into a corner? What panic buttons do you have nearby? What are the code words you can use to call for assistance” without further aggravating the assailant?
Getting assistance from specially trained staff is essential when, despite prevention efforts, a patient or visitor approaches the cusp of violence.
Increasingly more hospitals have created interdisciplinary groups of specialists to rapidly respond to incidents involving patients and visitors. The team that calmed down the UC Davis patient who spouted fury upon being awakened for medication was made up of (among others) a psychiatric nurse, mental health specialists, and members of teams that focus on safely lifting and transporting patients, says Danielle Kehler, JD, MA, director of employee and labor relations and workplace violence prevention. She says the staff of BEST, created in 2020, are on call to respond to requests for assistance with intervention.
“Let’s say we have a patient who is in a deteriorating emotional state,” Kehler says. “The staff has tried a few things but the situation is escalating. We want people to feel comfortable raising their hand when they believe it’s getting to a place that they can’t provide a clinical intervention.”
The interventions don’t have to come only for emergencies. At Wexner, “If a patient is having challenges with their care plan, with complying, and they’re becoming aggressive,” a team of nurses and other care givers (the Behavioral Emergency Response Team, established in 2019) works with the patient to get them on track, Seely says.
Safety teams also respond to threats aimed at specific workers — such as a doctor who performed a procedure that a patient is unhappy about — but those are rare. When staff receive such threats at Boston Medical, Packard says, the actions include conducting a background check on the offender (including criminal records and social media posts), helping the staffer inform police where they live, calling the person who made the threat, restricting access to the staff member’s work area, removing the staffer’s name from directories, and changing their parking spaces.
After an incident occurs, providing a written report is critical so that hospitals can know what aggressive acts are occurring and see where they might adjust procedures. The reports provide opportunities for frontline staff to debrief with safety teams about how incidents unfolded and how the responses worked. They also provide an emotional outlet for traumatized staff.
“It’s an opportunity to talk about their experience,” says Kehler at UC Davis. “What was scary? What was difficult? At what point did they feel that they sort of lost control of the situation or were left without skills that they believe they needed? Did everyone do everything that was within their control?”
Hospitals make changes based on those reports. For example, UVA Health’s reports show that delirium and dementia are the most common precipitating factors among aggressive patients. The system found ways to provide “quicker and easier access to certain medications to treat dementia and delirium patients,” with the hope that that will lower the anxiety and confusion that often leads to outbursts in some patients,” says Ava Speciale, MSN, RN, who co-chairs SAVE.
Those lessons show how increased training and reporting are essential to counteract increased aggression. Says Packard at Boston Medical, “The public safety teams are being called upon more than ever before.”