Reducing the risks of workplace violence

Training, communication are keys to prevention

When a distraught man shot a doctor, killed his mother and fatally turned the gun on himself at Baltimore’s Johns Hopkins Hospital last fall, the public learned what health care workers know all too well. The halls of healing aren’t immune to workplace violence.

In fact, health care workers are about three times more likely than workers in other industries to be injured by acts of violence, according to “State of the Sector/Healthcare and Social Assistance,” a report published by the National Institute for Occupational Safety and Health (NIOSH) in 2009.

Workplace violence in health care settings is increasing, according to the American Nurses Association. Of all industries reporting physical injuries from workplace violence, the health care sector tops the list.

“Most people think of guns and shooting when asked about workplace violence,” said Dan Hartley, an epidemiologist and workplace violence prevention coordinator at NIOSH. “But when I asked emergency room nurses at an Emergency Nurses Association conference this year, they talked about patients acting out, yelling, shoving, hitting by peers, supervisors or patients and their families. Violence can take many forms.”

NIOSH, a division of the Centers for Disease Control and Prevention that conducts research and makes recommendations to prevent work-related illnesses and injuries, defines workplace violence as overt or covert behaviors ranging from verbal harassment to murder. Violence can be verbal, psychological or physical.

“While most are simple incidents that don’t require first aid, most researchers agree that violence in hospitals is under- reported,” Hartley said.

There may be many reasons for that. Some health care workers may not speak up because no reporting procedures are in place, or because they fear being seen as unable to handle the job. Nurses in psychiatric or Alzheimer’s disease units may realize that the patients can’t help their behavior. Emergency room nurses may see dealing with abuse from patients under the influence of drugs or alcohol as part of the job.

“It shouldn’t be,” Hartley said. “No one should expect to be hurt at work.”

Besides physical injuries, workplace violence can cause loss of productivity, higher insurance costs, property damage, higher employee turnover or low morale, NIOSH reported. Forty-five percent of nonfatal assaults against workers resulted in lost work days, said a U.S. Bureau of Labor Statistics 2006 report.

Fortunately, Hartley has seen more hospitals address the issue by implementing workplace violence prevention programs in the last five to 10 years. The Joint Commission spurred prevention activities by putting in place new leadership standards in 2009. Accredited organizations must have a code of conduct that defines acceptable, disruptive and inappropriate behaviors and a process for managing them.

Grady Health System in Atlanta strives for a respectful and safe working environment through various means including heightened security measures, training, leadership development and clear policies for reporting, documenting and evaluating violent incidents.

“We train everyone. Every new hire, vendor, student, intern and medical affiliate receives hospital orientation training, which includes violent-crisis prevention. Our 5,300 employees also get a refresher course annually,” said Marilyn Morales, director of training and organizational development for Grady Health System.

“We teach our employees about their risks and how to recognize the warning signs of impending violence, how to resolve conflicts and how to report incidents. We hope that the training kicks in when an incident happens, because violence is always lurking around the corner. If it could happen at Johns Hopkins, it can happen anywhere. Our job is to limit risks to Grady employees and visitors.”

That hospitals, whose mission is to heal, should be among the most dangerous places to work doesn’t surprise Dallas Terry, director of public safety at Grady Health System.

“Health care workers deal hands-on with the public, often during high-stress situations,” he said.

On the front line of care, nurses and nurses aids are often the victims.

“Our emergency medical centers and psychiatric units have higher risks for violence,” Terry said. “Patients or family members may come in under the influence of alcohol or drugs. Mental health patients can experience agitation, sudden mood swings and uncontrolled behaviors.”

Waiting rooms and geriatric units also have high-risk potential for violence, according to NIOSH. Crowded conditions also can lead to conflict.

“Patients don’t understand that we have to see more seriously injured patients first in the ER, even if they’ve been waiting longer,” Terry said.

Understaffing also can cause problems. An 18-month NIOSH study from 2003 and 2004 found that as the number of patients per care provider increased, so did the number of assaults.

“When hospital workers had one to five patients, 23 percent experienced an assault,” Hartley said. “The percentage rose to 27 percent for workers with six to eight patients and 39 percent for workers with 11 patients or more.”

Grady officials don’t take workplace violence lightly.

“Our policy is to take every act of violence seriously, to document it, evaluate it and take appropriate actions,” Morales said.

Terry has beefed up the hospital’s physical environment through better lighting in parking lots, metal detectors, controlled-access doors and camera surveillance in high-risk areas.

“We want to make sure that fewer weapons enter our building and that has made a significant difference in reducing incidents,” Terry said. “We have installed special lighting systems in our clinics, so that if there’s a problem in an examination room, a light goes out at the reception desk and people come to help.

“People tend to act out when someone is working alone, so calling for help from co-workers is a good deterrent.”

Hospital security officers hold frequent in-service training sessions with units to alert them to specific risks in their area.

“We don’t teach them judo, but we do teach them verbal judo, so that they can recognize pre-incident indicators and use words, tone of voice and body language to calm down angry clients and defuse potentially explosive situations,” Terry said. “When those don’t work, we tell them to exit the situation and call for security.”

Strategies for dealing with conflict between co-workers is also key to making work environments safer.

“Creating a respectful workplace where everyone is considered everyone else’s customer is key to preventing lateral violence [verbal or physical violence between co-workers],” Morales said. “We equip our leaders with conflict-resolution skills and we ask them to always provide answers in a timely fashion so that dissatisfactions don’t escalate.”

Because problems at home often follow employees to work, leaders at Grady are coached to watch for unusual behaviors that might occur because of a divorce, family illness or financial problems, Morales said. Grady’s Employee Assistance Program gives employees a place to talk and get counseling and other forms of help. Safe workplaces raise awareness about risks, provide training and keep the channels of communication open, she said.

If an employee crosses the line and breaks the hospital’s conduct policy, consequences may include suspension, termination or legal prosecution.

Terry believes that training makes a big difference.

“We spend a considerable amount of time in training because we have to be ready for anything,” he said. “You can never have enough training. Because of training and security measures, we’ve seen significant improvement in the number of violent incidents. On the whole we’re staying on top of it.”