Addressing the Problem of Hospital Violence

By Debra Wood, RN, contributor

March 2, 2011 - Violent acts in a healing environment sounds oxymoronic, but hospitals and other health settings can be dangerous places, filled with individuals under stress, impatient or in crisis with little coping ability left from which to draw.

“Workplace violence has been increasing, and the healthcare workplace has a lot of risk,” said Nancy L. Hughes, MS, RN, director of the Center for Occupational and Environmental Health of the American Nurses Association. The center is currently working on a violence prevention training module for nurses with the National Institute for Occupational Safety and Health (NIOSH).

“Nurses are getting attacked, more than just in the psychiatric and emergency departments,” Hughes said. “People are bringing weapons into facilities.”

AnnMarie Papa
AnnMarie Papa, DNP, RN, CEN, NE-BC, FAEN, said no gray areas can exist when it comes to determining acceptable behavior.

Last year, a nurse was shot by a patient at Danbury Hospital in Connecticut and a family member shot a doctor at Johns Hopkins Hospital before turning the gun on his loved one and himself.

“We work in an environment and society that is becoming more and more violent, which is unfortunate,” agreed AnnMarie Papa, DNP, RN, CEN, NE-BC, FAEN, president of the Emergency Nurses Association (ENA).

The Emergency Nurses Association has developed the customizable ENA Workplace Violence Toolkit, with information for evaluating risks, developing a prevention plan and responding appropriately. This free resource provides assessment tools, staff competency indicators, safety event reports and other valuable information.

Kate McPhaul, PhD
Kate McPhaul, Ph.D., MPH, RN, said changing the culture to reduce violence against staff requires an upper-management commitment.

“This is good stuff, very practical, and consistent with the research and the Occupational Safety and Health Administration,” said Kate McPhaul, Ph.D., MPH, RN, assistant professor at the University of Maryland School of Nursing Work and Health Research Center in Baltimore. Although developed for the emergency room, the risk assessment and plan development process should take place on all units.

“Getting upper-level administration involved is essential,” McPhaul added. Motivators include Joint Commission requirements, collective bargaining, workers’ compensation costs and consumers’ perception of safety. However, nurses often can use high-profile cases to call upper management’s attention to the issue.

Reducing workplace violence requires support for a culture of safety, not just for patients but staff, said Roberta Carroll, RN, MBA, senior vice president of Aon Risk Solution’s health care practice in Tampa.

“The responsibility for creating a civil culture and consequences rest with the employer,” added Jonathan Rosen, director of the Occupational Safety & Health Department at the New York State Public Employees Federation in Albany, agreeing that patient and staff safety go hand in hand.

“There has to be a line in the sand about what is acceptable and is not acceptable,” Papa said. “Gray areas do not work.”

Preventing violence

Hospitals must evaluate the likelihood of violence, considering the facility’s location, gang activity and past history, as well as focusing on higher-risk units, such as emergency, psychiatric and intensive care, Carroll said.

Assessment begins with the physical environment: lighting, windows, alarm systems, etc. Papa recommends letting people from different departments assess the risks as well, as they bring a fresh perspective.

Carroll takes that a step further, inviting law enforcement to assess risks and participate in developing a plan.

Hospitals must balance a welcoming, customer-service ambience with safety, McPhaul said. Closing entrances and stationing guards and metal detectors at each entryway could turn off patients.

Regardless of perceived risk, Hughes said nurses should never work alone. There should always be another person on the unit or in the department.

Nor should nurses let their guard down, Carroll added.

Persons with a history of violence present greater risk than those who have not acted out before, but emergency department nurses often don’t have much information about the patients’ history, McPhaul said.

As people wait for care, tension builds and people may act out, said Sean Ahrens, senior security consultant with Aon Risk Solutions.

Physical assaults often appear to occur in a flash, yet a trained professional usually can spot signs a situation may be worsening and diffuse trouble.

“Nurses need to learn to recognize when the situation is escalating and how to keep themselves safe,” said Hughes, offering as an example a person raising his voice or clenching his fists. The NIOSH modules will include these and other tips.

Training can prove effective to break the continuum of violence in patient-staff interactions, said Ahrens, recommending the nurse or other staff member acknowledge the problem, show concern, speak softly, smile, demonstrate listening, maybe offer to reduce the bill or provide food or a beverage.

Interventions also might include a rapid response team to deal with behavioral issues and help talk the patient down, Papa said.

Responding to an event

Established policies are important for a prompt, correct response, said Howard Gwon, senior director of the office of emergency management at Johns Hopkins Medicine, who credits the health system’s policies with allowing the fast securing of the unit where the shooting occurred.

Afterward, the hospital provided debriefings and encouraged employees to express their feelings or concerns about the incident. Gwon also recommends establishing redundant communication methods, so if, for instance, telephones are not working, security, police and others outside the unit can talk with people in the contained area.

Victims must feel heard. Supervisors, peers and colleagues must not minimize the incident, consider it part of the job or make excuses for the perpetrator.

“What nurses want is that the organization responds to them, acknowledges the behavior occurred and finds what the nurse needs to deal with that incident,” Papa said. That may include medical care, debriefing and/or counseling.

Rosen reported success with peer trauma-support teams, available on all shifts, to help the person regain a feeling of safety and avoid the risk of post-traumatic stress disorder. Supervisors must support the program and allow peer counselors time to respond.

However, at many hospitals, such support is not the case. ENA research indicates in almost half of the cases of physical violence, nurses reported that no action was taken against the perpetrator, and in three out of four cases, hospitals did not respond to nurses’ reports of violence.

McPhaul indicated those numbers are consistent with other findings. She said employers, not just in healthcare, often do not want to think about violence.

Nurses can report assaults to the police, but they may not receive support from their organizations. Also, in psychiatric settings, district attorneys often will not prosecute such assault cases, McPhaul said.

The same goes if no physical injury occurs, added Rosen, saying it becomes a harassment case. Yet every person experiencing an assault will suffer from traumatic symptoms.