Even before the onset of the COVID-19 pandemic, health care workers suffered more workplace injuries as a result of violence than any other profession, with approximately 654,000 harmed annually, according to American Hospital Association studies.¹ Since the pandemic began, violence against hospital employees alone has markedly increased. For example, 44% of nurses reported an increase in physical violence and 68% reported an increase in verbal abuse.¹

The Joint Commission defines workplace violence as an act or threat occurring at a workplace that can include: verbal, non-verbal, written, or physical aggression; threatening, intimidating, harassing, or humiliating words or actions; bullying; sabotage; sexual harassment; physical assaults; or other behaviors of concern involving staff, licensed practitioners, patients, or visitors.²

Dr. Persoff

When asked if violence has increased at his hospital, Jason Persoff, MD, SFHM, an associate professor of medicine in the division of hospital medicine at the University of Colorado Hospital in Aurora, Colo., an urban, adult, academic hospital with 850 beds, said patients are becoming increasingly outspoken and dissatisfied with care due to limited visitor access to patients, increased delays in care due to overrun hospitals, and care at the hands of some burned out clinical staff.

In addition to that, after losing nearly one-third of all health care workers to the pandemic,^3,4 there is an exceptionally new, green workforce in place which results in more challenges as they grow as clinicians. “Frustration and misinformation have further demoralized clinicians and simultaneously created an antagonistic relationship from time to time as patients argue about what is and isn’t scientific fact,” Dr. Persoff said.

Dr. Webb

Nicole E. Webb, MD, FAAP, program director of the pediatric hospital medicine fellowship at Valley Children’s Hospital, a free-standing tertiary children’s hospital with 358 beds in Madera, Calif., blames a dramatic shortage of outpatient mental health resources for contributing to the increased violence at hospitals. “Part of it is a supply and demand issue, which stems from the fact that mental health care isn’t reimbursed at a rate even remotely commensurate with medical services in this country,” she said. “Because of this, many mental health practitioners are private pay or cash pay and there are far more patients who need their services than providers to see them. For publicly insured patients, the shortage is even more severe.”

Dr. Harris

Che Matthew Harris, MD, a hospitalist in the department of medicine at Johns Hopkins Bayview Medical Center in Baltimore, an academic hospital with 420 beds, believes that as a society, Americans are under a stressed system which has led to a lot of anxiety, anger, fear, and distrust. “This may lead people to act out more aggressively and violently,” he said. “Multiple factors are contributing to this worsening crisis, such as under-addressed mental health care needs, the opioid epidemic, unemployment, and an increased division in politics.” In addition, the impact of COVID-19 resulted in death, isolation, and uncertainty about the future, which has also increased stress levels.

Training and education

In today’s society, hospital staff must be well-prepared to deal with violence. Training and education are necessary. Employees at the University of Colorado Hospital, for example, are trained on how to use communication tools to minimize conflict and build therapeutic relationships with patients and families. They’re also trained to identify issues when situations are escalating and how to use de-escalation tools.

Most situations are focused on prevention and are ultimately successful. “We take a zero-tolerance approach to belligerent or violent behavior and will work with police to protect staff from provocateurs and violent individuals,” Dr. Persoff said.

Staff also learn how to respond to violence when it explodes, including where they can hide in safe rooms from active shooters or other violent acts.

Occasionally Dr. Persoff’s hospital has had trespass visitors or repeat offenders. “All patients are entitled to an Emergency Medical Treatment and Labor Act screening exam, whether or not they have a history of violence,” he said.

This act requires hospitals with emergency departments (EDs) to provide a medical screening examination to any individual who comes to the ED and requests such an examination and prohibits hospitals with EDs from refusing to examine or treat individuals with an emergent medical condition. “We don’t allow our employees to be bullied, screamed at, attacked, or threatened,” Dr. Persoff said.

Dr. Gupta

As part of employee education, Valley Children’s has mandated modules on dealing with violence. “Most incidents involve behavioral health patients; additional training is primarily targeted toward nursing and ancillary bedside staff,” Dr. Webb said. The hospital’s security department has a de-escalation program that’s offered to higher-risk areas such as the ED. The training is also available upon request.

Hospitalists at Johns Hopkins Bayview Medical Center underwent four hours of crisis-prevention training, which included training on violence triggers, early identification of signs of aggression, how to de-escalate an agitated patient, and basic self-defense skills to prevent injury, said Ishaan Gupta, MBBS, an assistant professor of medicine in the division of hospital medicine at the Center.

Prevention plans

Dr. DeFoster

The Mayo Clinic has implemented multiple forms of prevention plans including everything from violent-patient flags in electronic medical records to passive weapons detection at key access points, said Ruth DeFoster, MD, a hospitalist in the department of medicine at the Mayo Clinic in Rochester, Minn., an academic hospital with 1,265 beds. Staff is encouraged to use its multi-disciplinary behavioral emergency response team before an act of violence occurs. The team includes security personnel and has a close working relationship with local law enforcement.

Johns Hopkins Bayview Medical Center installed magnetometers with increased security at the walk-in entrance of its ED. “This should help prevent and deter individuals from bringing weapons to the hospital,” Dr. Harris said. “We’re also working on bolstering de-escalation training for all staff; I’m hopeful that adequate training will help reduce aggression and violence.”

Response plans

Johns Hopkins Bayview Medical Center has a code-green team that responds to aggressive or violent patients in the ED after de-escalation strategies have failed. This team is comprised of security guards, nurses, physicians, and behavioral specialists. “The code-green team has been successful because of its multi-disciplinary approach used for intervention,” Dr. Harris said. Each member brings a unique quality and perspective on what may drive a patient to be violent and the best steps needed to control a situation.

Dr. Schulwolf

Elizabeth Schulwolf, MD, MBA, FACP, FHM, chief medical officer at Dell Seton Medical Center at the University of Texas (Ascension) in Austin, a level-one trauma center with 210 adult beds, has onsite security to respond to escalating situations in the ED or inpatient areas. It recently increased security staffing both inside the hospital and in the parking garage adjacent to the hospital.

Behavior agreements are put in place for hospitalized patients who are verbally or physically abusive toward staff or those who present a danger to others. Patients are informed of the hospital’s expectations for creating a safe environment. “If they’re unable to meet the expectations, they are discharged from the hospital with care coordinated as best as possible,” Dr. Schulwolf said.

When patients at the University of Colorado Hospital have profound complex psychosocial care issues and are unable to make their own health care decisions, specialized teams are designated to lead in those patients’ care to optimize outcomes for the patients and staff alike, Dr. Persoff said. Teams focus on supporting the patient while also setting expectations for appropriate behaviors.

Reporting policies

Johns Hopkins Bayview Medical Center encourages reporting all workplace-violence incidents; a dedicated online form can be used and completed anonymously. “Now that the Joint Commission issued revised standards in 2022, I expect that there will be more robust reporting methods,” Dr. Gupta said.

A survey study within the hospitalist division noted that more than 85% of all workplace-violence incidents weren’t reported. “Workplace violence is so ingrained in the day-to-day work of health care workers that they have come to accept it as a part of their job,” Dr. Gupta said.

“Effective reporting is one of the first areas which needs renewed focus,” Dr. Gupta said. “There should be multiple methods of reporting which are user-friendly and, very importantly, without retaliation. Reporting should lead to discernible action for frontline staff.”

At the Mayo Clinic, the staff is also encouraged to report acts of violence. “A supportive environment has highlighted the fact that no one needs to tolerate violence as part of their job,” Dr. DeFoster said.

Hospitalist’s roles

Dr. Gupta recommends de-escalation training for all hospital-based clinicians. The training would empower them to use the right tool for the right patient at the right time. He suggests three specific interventions which would be useful in all situations.

Ensure safety for yourself and your patients. Ensure clear access to an exit, remove personal items which can be used as weapons (such as stethoscopes and jewelry), and be aware of your surroundings.

Manage your own emotions. Be mindful of your verbal and non-verbal responses to patients. To de-escalate an angry patient, your tone and body language are sometimes more important than the words themselves.

Explore the reasons for aggression. Aggression may be a symptom of an underlying medical problem such as delirium or psychosis. It could also be related to interpersonal conflict or related to hospital policies. Each type of problem requires a different approach to resolve it.

When patients are aggressive or abusive, Dr. Persoff said the first step is to understand why they’re behaving that way. For example, is there a physiologic reason or an underlying disease process that may cause a patient not to recognize that their behavior is out of bounds? “Don’t internalize their comments or epithets; this isn’t about you, the clinician,” he said. “It’s about a complex issue that a patient or visitor is grappling with.”

Most importantly, Dr. Persoff said it’s imperative that clinicians are trained in how to work through complex interactions with techniques that can be learned and practiced every day. For example, the Institute of Healthcare Excellence offers courses designed to be used throughout an institution or health care system to learn how to listen actively and use language that fosters connection and respect.

Dr. Persoff maintains that no one should accept abuse as part of their job. “Any staff member who has been threatened or attacked should be offered the emotional space and psychological care needed to deal with a traumatic experience,” he said.

Dr. Schulwolf recommends that hospitalists support nursing staff in enforcing acceptable behavior. “Physicians have a strong voice in setting expectations in the hospital when patients are able to manage their behavior,” she concluded. 

Karen Appold is an award-winning journalist based in Lehigh Valley, Pa. She has more than 25 years of editorial experience, including newspaper reporter, and newspaper and magazine editor.

References

1. Alexander AE, et al. Navigating the hazard of rising violence in health care facilities. Reuters website. https://www.reuters.com/legal/litigation/navigating-hazard-rising-violence-health-care-facilities-2022-05-17/.  Published May 17, 2022. Accessed February 6, 2023.
2. Workplace violence prevention resources. The Joint Commission website. https://www.jointcommission.org/resources/patient-safety-topics/workplace-violence-prevention/. Accessed February 6, 2023.
3. Yong E. Why health-care workers are quitting in droves. The Atlantic website. Available at: https://www.theatlantic.com/health/archive/2021/11/the-mass-exodus-of-americas-health-care-workers/620713/. Published November 16, 2021. Accessed February 6, 2023.
4. Galvin G. Nearly 1 in 5 health care workers have quit their jobs during the pandemic. Morning Consult website.  https://morningconsult.com/2021/10/04/health-care-workers-series-part-2-workforce/. Published October 4, 2021. Accessed February 6, 2023.