Mitigation & Management

Once a threat has been identified, investigated and assessed, the final component of TA is management and mitigation.  These strategies are broken down in different ways but usually involve approaches for low, moderate and high risk threats; approaches related to the perpetrator of the violence such as intimate partner or disgruntled employee; or a combination of the two.  This article will group mitigation strategies by the types of violence that were described in Table 1.

General Strategies (applicable to all types)

  • Coach employees who may be confronted by potentially aggressive individuals. The employees should be encouraged to remain calm, show respect and use active listening skills. In addition, they should not use challenging or apathetic communication that can further agitate the aggressor and contribute to the escalation of violence. Consider providing de-escalation training for staff.
  • Incidents involving a clear law violation should be referred to law enforcement for investigation and possible legal action. The TA team should carefully weigh the potential risks and benefits of requesting law enforcement consultation for issues that do not presently involve violation of the law because involving law enforcement may escalate a situation.
  • Some unusual, inappropriate, but not immediately dangerous behaviors can often be addressed by securing the assistance from family, friends, neighbors or co-workers.
  • Organizations must sensitize all employees to recognize warning signs and how to assist employees and customers who are stressed, suicidal, burned out, or experiencing severe personal problems before they reach the breaking point. Have materials available to provide referrals to employee assistance programs, rape crisis centers, intimate partner violence counselors and mental health agencies.[73]

Type 1 (someone unassociated with the organization)

TA would not be applicable to this type of violence.  This type is best managed through RA and engineering controls.

Type 2 (client/customer)

  • Implement a patient flagging process. Patient flagging is quickly becoming a best practice to mitigate patient/family violence.  A patient safety flag is an alert, typically within the electronic health record, that notifies staff that the patient is potentially a safety risk due to a history of violent/threatening behavior.  The International Association for Healthcare Security and Safety (IAHSS) guidelines recommend three levels: awareness, immediate threat and termination from care.[74] An acute care plan should accompany any flag placed.  The plan should describe steps staff can take to maintain safety specific to the patient, such as entering the room slowly, avoiding loud noises, specific gender preference for care, triggers for aggression, etc.  The flag itself is only an alert for staff of a potential history of threats or violence but will not, by itself, make staff safer. Working together to proactively plan for each patient situation for optimal staff protection is the best way to maintain safety.[75]
  • Take angry complaints about the care of family members seriously, especially if there is a bad outcome. These complaints should be thoroughly investigated and referred to Patient Advocacy or Case Management as appropriate.[76]
  • Develop a Rapid Response Team. If a patient has had previous violent encounters with staff or is flagged for violence in the electronic health record, a team should be quickly convened the next time the patient presents for treatment to establish a care management plan.   Some hospitals are using this multi-disciplinary team approach with unanticipated violence in addition to targeted violence with excellent results.  Though further research is needed in this area, a 240-bed community hospital that implemented a violence rapid response protocol saw a reduction in restraint and seclusion for behavioral health patients from 30% to 1%.  Fewer instances of restraint and seclusion meant fewer hands-on altercations and fewer staff injuries.[77]
  • Carefully consider whether it is the best course of action to dismiss a patient from a practice.  While this might seem like the right approach, it could also further escalate the situation.  According to Sheridan Ryan, Associate Director of Risk Management at the Medical College of Wisconsin, “A thorough TA investigation may reveal the threatening behavior to be indicative of a new or undertreated medical or psychiatric problem that the provider or other providers in the organization are capable of addressing. Maintaining a treating relationship with the patient can offer the ability to monitor for safety and intervene as warranted.”[78]
  • Management plans “may include noninvasive interventions (e.g., conversation with the individual or individuals; written letters expressing behavioral expectations) to more restrictive approaches (e.g., limiting the time, place or manner in which safe and effective health care may be delivered).” [79] Some other mitigation options recommended by IAHSS to include in the management plan are:
    • Environmental changes to the treatment room including removal of all unnecessary equipment and furniture
    • Implement patient search protocols to eliminate any items that might be used as a weapon
    • Thoroughly search and secure any personal property brought into the treatment area
    • Maximize observation and response capabilities by assigning additional staff to the area
    • Create visible or auditory methods to alert non-clinical staff such as dietary or environmental services to the potential for violence
    • Introduce and reinforce behavioral expectations
    • Medically approved patient restraints[80]

Type 3 (terminated or disgruntled employee)

  • Terminations are a leading violence trigger. Security should be in the room during termination actions determined to be moderate to high risk to provide a deterrent to violent acting out.  Consider supplementing with armed security or law enforcement to bolster this deterrent if not typically available at the organization.  Consider a termination policy that allows for terminations to be conducted some place away from the workplace and/or performing high risk terminations by phone and shipping personal belongings.[81]
  • Voluntary separation over involuntary termination is an essential risk mitigation strategy. The natural reaction in the face of threats or acts of workplace violence is to immediately fire the offending employee before a complete TA investigation is performed.  Firing the offender ensures there is a loss of contact and loss of rapport.  Conversely, offering the offender the opportunity to voluntarily resign allows the employee to leave with dignity. It also creates a mindset of compassion and being treated with fairness, which may diminish the desire to strike out violently against the organization.[82]
  • Pre-employment and periodic employee background checks should be industry standards. The majority of healthcare workers are subject to a background check when initially joining an organization, but it is not common to repeat those checks throughout their career. An updated background check should be conducted and evaluated by the TA team whenever concerning behavior is being investigated.[83]
  • Disgruntled employees, whether they continue with the organization or separate, should have a formal case file opened and their behavior monitored if they have the potential to be a threat.
  • Angry employees are typically knowledgeable of organizational policies and procedures. Keep all non-public entrances locked. Consider door alarms; consider altering procedures if a disgruntled employee is determined to be a high risk for violence.

Type 4 (intimate partner)

  • Foster a culture that is supportive, respectful, non-judgmental and open. Manage the situation with empathy and respect with a focus on preserving dignity. If the employee feels compassion from the organization, he/she is more likely to share critical information and seek assistance if the situation escalates.
  • Establish a confidential helpline (different from compliance hotlines) to which issues can be raised without requiring face-to-face contact with management.
  • Meet with threatened employee to offer guidance and support such as moving his/her work location or parking spot, providing portable duress alarms and changing his/her work schedule.  Provide information on local and national support resources for intimate partner violence victims and recommendations for enhanced personal safety such as the power in numbers, being alert to the environment, trusting intuition and not establishing patterns.  Provide guidance on the legal protections available such as obtaining a restraining order/order of protection; however, be cautious about recommending a particular legal course of action. [84]

 

[73] Kenny, Risk Assessment and Management Teams, 168

[74] IAHSS Violence Management Recommendations Standard, IAHSS.org

[75] https://www.brighamandwomensfaulkner.org/about-bwfh/news/patient-safety-flagging-faq

[76] Caroline Ramsey-Hamilton, (2019). http://www.riskandsecurityllc.com/

[77] Elizabeth C. Kelley, Reducing Violence in the Emergency Department: A Rapid Response Approach, (Journal of Emergency Nursing, 2014), 61.

[78] Ryan, Healthcare Threat Management, 2.

[79] Wyatt et. al., Workplace Violence in Health Care, 1038.

[80] Viole8nce Management Recommendations Standard, IAHSS.org

[81] Caroline Ramsey-Hamilton, RiskAlert Report #1146, (2019).

[82] https://losspreventionmedia.com/mitigating-and-managing-threats-and-acts-of-workplace-violence/

[83] Caroline Ramsey-Hamilton, (2019). http://www.riskandsecurityllc.com/

[84] https://www.securitymagazine.com/blogs/14-security-blog/post/88084-preventing-domestic-violence-in-the-workplace