Spectrum of Violence Broad and Varied

Violence against healthcare workers may commonly include verbal disturbances, physical assaults, and countless instances of other dangerous behaviors. It is vital that healthcare staff understand that the risks of violence from patients should not omit the potential for active assailant events. While findings from the FBI’s Active Shooter Incidents Study from 2000-2013 revealed only four active shooter incidents occurring in healthcare settings, with two additional incidents occurring between 2014-2015, the potential for this type of violence is not zero. According to a study in Annals of Emergency Medicine, from 2000-2011, the United States had 154 hospital-related shootings:

  • 91 (59 percent) inside the hospital and 63 (41 percent) outside on hospital grounds
  • 235 injured or dead victims
  • The Emergency Department environs were the most common site (29 percent), followed by the parking lot (23 percent) and patient rooms (19 percent)
  • Most events involved a determined shooter with a strong motive defined by a grudge (27 percent), suicide (21 percent), “euthanizing” an ill relative (14 percent), and prisoner escape (11 percent)
  • Ambient society violence (9 percent) and mentally unstable patients (4 percent) were comparatively infrequent
  • Hospital employees composed of 20 percent of victims. Physicians (3 percent) and nurses (5 percent) were relatively infrequent victims
  • In 23 percent of shootings in the Emergency Department, the weapon was a security officer’s gun that was taken by the perpetrator (FBI Active Shooter Planning – Response in Healthcare Setting, 2017).13

Since workplace violence is a global concern, it is important to consider the work of noted organizations such as the International Association for Healthcare Security and Safety (IAHSS), which has worked with multiple countries around the world. In an effort to predict violence from psychiatric patients, Canada has developed a real-time analytics tool that uses computer software and coding to evaluate the risk of patient violence and communicate it through a database. From the results, employers are able to prescribe appropriate measures and treatment.14

Preparation, Training and other Efforts to Mitigate Violent Behaviors

While no program or methodology can boast foolproof success, there are some standard considerations for mitigating the risk of violence by patients against healthcare workers. OSHA 3148 Guidelines propose the following:

Preparation and Situational Awareness

Staff should be trained to recognize hazards and common cues related to workplace violence early on. Upon noting potential violence, staff should have a plan for what to do to avoid being victimized, as well as to communicate the potential of violence to other teammates. Additional points to consider include:

  • Risk factors that cause or contribute to assaults
  • Policies and procedures for documenting patients’ or clients’ change in behavior
  • The location, operation and coverage of safety devices such as alarm systems, along with the required maintenance schedules and procedures
  • Early recognition of escalating behavior or recognition of warning signs or situations that may lead to assaults

Formal training of healthcare staff should be conducted by qualified trainers. Effective training should be provided to all staff who interact with patient and should involve role- playing, simulations and drills. Frequent and ongoing refresher training should be emphasized for staff members in high-risk settings. Training should consider:

  • Ways to recognize, prevent or diffuse volatile situations and aggressive behaviors, manage anger and appropriately use medications
  • Ways to deal with hostile people other than patients and clients, such as relatives and visitors
  • Proper use of safe rooms – areas where staff can find shelter from a violent incident
  • A standard response action plan for violent situations, including the availability of assistance, response to alarm systems and communication procedures
  • Self-defense procedures where appropriate
  • Progressive behavior control methods and proper application of restraints
  • Ways to protect oneself and coworkers, including use of the “buddy system”
Patient Sitters

Hendrickson (2017) suggests that another consideration for mitigation of patient violence is the use of patient sitters. These staff are trained to observe, on a one-to-one basis, patients who are at high risk for falls, elopement, behavioral health issues, or homicidal or suicidal inclinations. Their training may include elements related to de-escalation techniques, identification and management of aggressive patient behaviors, fall and suicide prevention, etc. The inclusion of such staff could provide another level of situational awareness concerning high-risk patients.15

Documentation and Communication

A Sentinel Event Alert Supplement (TJC Publications Issue 57) emphasized key characteristics for staff to maintain a culture of safety:

  1. Leaders demonstrate commitment to safety in their decisions and behaviors
  2. Decisions that support of affect safety are systematic, rigorous and thorough
  3. Trust and respect permeate the organization
  4. Opportunities to learn about ways to ensure safety are sought out and implemented
  5. Issues potentially impacting safety are promptly addressed and corrected commensurate with their significance
  6. A safety-conscious work environment is maintained where personnel feel free to raise safety concerns without intimidation, harassment, discrimination, or fear of retaliation safety is maintained