Strength Through Collaboration: Forming a Healthcare Workplace Violence Committee

According to the most recent statistics released by the Bureau of Labor Statistics, the level of violence in hospitals across the United States continues to increase at a steady rate.  For 2018, healthcare workers topped all other private industries in nonfatal intentional injuries by another person with an incidence rate of 10.4 per 10,000 full time workers.  This is in comparison to an incidence rate of 2.1 for all other private industries.

This is a startling rate of violence against our front-line healthcare workers.  However, for those who work in healthcare and experience hostility and violence regularly, the statistics are not surprising.  Today, I’d like to focus on one thing that you can be doing right now to help mitigate the ever-present and ever-increasing threat of violence in your hospital- creating a multidisciplinary workplace violence committee.  

Committee Membership 

The problem of workplace violence can’t be resolved by the Security Department alone. Violence impacts employees across all areas of the hospital- not just in higher-risk areas like the emergency department and the psychiatric unit.  Anyone working in any area can experience violence, from verbal and psychological abuse to physical attacks at the hands of patients, visitors, co-workers and others.  Forming a committee brings together the voices and minds of staff from key areas within your institution to work together towards a common goal of preventing and mitigating workplace violence.  That being said, you’re probably wondering who should be on this important team.  Here’s my suggestions for membership:

1. Executive Sponsor (Vice-President level)

2. Security Director

3. Human Resources Director

4. Risk Management Director

5. Inpatient Nursing Director

6. Outpatient Nursing Director

7. Domestic Violence Program Manager (where applicable)

8. Employee Assistance Program Manager

9. Emergency Department (ED) Nurse Manager & Chief Physician

10. Psychiatric Unit Manager and/or Chair of Psychiatry

11. Safety Manager

12. Occupational Health Manager

13. Staff Education Manager

14. Line staff representation (one from each area) from: ED, selected inpatient unit, and support services).

Your team membership will obviously vary depending on the size of your hospital or healthcare organization, organizational structure, clinical program offerings, and other factors.  However, the idea here is to get the people at the table who can contribute ideas, make decisions, and take action when needed.  

Now, getting all of these people to the table in one place at the same time can be like herding cats- believe me, I understand!  But, the results that the team can accomplish are well worth the three hours you’re going to spend sifting through everyone’s crazy schedules.  This is where the executive sponsor can come in handy.  It’s important to seek out someone in the C-suite who is willing and able to support this initiative.  I can’t tell you who this will be, but it can vary from a clinical VP to the Chief Operating Officer (COO).  The VP-level interest in the initiative will be helpful in getting the top dogs at the table for the first time.

I Have My Team Assembled- Now What?

Ok, so now you have your team assembled and you’re at the table for the kickoff meeting- where should you start? Well, for one, you should talk about what you want to see the team accomplish.  This will help you form your workplace violence charter, which is critical to the success of the committee.  Don’t forget to educate the members on what workplace violence is, where it happens, and the statistics from across the country and from your own institution.  Where are the areas of concern in your organization?  What keeps you up at night? What worries the hospital community?  Next, get input from the committee on what they see as important areas of focus.  This initial discussion will help you decide the key areas to focus upon, from which you can derive the first goals for your team.  Take it from me- don’t just meet and talk about things- form concrete goals and work as a team to accomplish them.  This will keep the team focused and motivated.

Other Committee Logistics- From Leadership to Reporting

• How often should you meet?  Given the membership, it can be hard to get together frequently.  My suggestion is to start meeting every other month for the first year of the committee.  This frequency will help work out the kinks of the team and to keep their eyes on the preliminary goals.  After that, you might move to a quarterly meeting.

• Who should lead the team?  I suggest a co-chair leadership model.  Ideally, one of the co-chairs should be a clinical leader and the other should be a non-clinical leader, such as the Director of Security or Risk Management.  Select people who are invested in making the committee a success and who have the bandwidth to pull it off.

• Who should you report out to?  Given the nexus to safety, it makes sense in most cases for the committee to report out regularly to the Environment of Care Committee (aka- the Safety Committee).  Reporting out to another group will give you and your team both publicity and accountability.  Further, you may also want to have the committee report on a less frequent basis to the organization’s board of directors.

Time To Get Started!

I can tell you from my own personal experience that a multidisciplinary workplace violence committee, when properly formed and maintained, can help you make great strides in tackling this threat to your healthcare organization.  As a bonus, for the most part, this is a no-cost solution that can be implemented fairly quickly and easily.  So, if you don’t have a team, what are you waiting for?

What best practices can you recommend from starting and running a workplace violence committee?

Attacking the Root of Healthcare Violence: Beyond Security Measures

Image Credit: Canva

How many times have you seen this happen?  An awful instance of workplace violence by a patient at a hospital makes the local or national headlines.  The media takes the story and runs with it.  Then the impacted hospital puts out the standard issue response that goes something like this: “At [insert hospital name here], we take the safety and security of our staff, patients, and visitors seriously.  We are investigating this incident and cooperating with local law enforcement.  In response to this incident, we are adding more security officers, installing security cameras, adding panic alarms and [insert additional security theater measures here].”  

Sound familiar?  I just wrote that blurb from memory because I’ve read it so many times.  Here’s the problem with that statement- while it may appease the public, the clients of the hospital, and maybe some employees, it represents a problem with the mindset that some healthcare organizations have regarding workplace violence.  You see, the statement suggests that these measures are what actually will help stem the issue of workplace violence by patients.  How many times have you seen footage of violence in a hospital recorded on security cameras?  What about panic alarms?  Do those prevent violence or simply provide a means to report it once it is already happening?  I think you get the idea here.  All of these measures are an important part of the layered approach to providing security within the hospital, but they don’t necessarily get to the root of what causes patient violence, which is the most prevalent type of violence in hospitals.  

The root of patient violence is clinical in nature and, therefore, must be addressed at the clinical level.  The vast majority of patients who assault staff don’t do it because they are sadistic, violent people who like to hurt others- they do it because their underlying condition causes them to act out aggressively.  For example, a 2014 study from the Journal of Hospital Medicine found that “Delirium affects up to 82% of critical-care patients and 29% to 64% of general medical patients…”  The study found that “Delirium preceding...combative behavior was present in 50% of patients with combative behavior requiring intervention…”  So, what does this mean for violence prevention and mitigation?  It means that assessing and treating patients for delirium can help mitigate violence against caregivers.  This is just one example of a clinical intervention that can prevent violence. 

“The root of patient violence is clinical in nature…”

Have you seen any studies that have statistically indicated that security cameras prevent violence lately?  I didn’t think so.  What about panic alarms- any research on how they prevent or mitigate violence?  These are both helpful tools as part of a layered security approach, but they don’t prevent violence.  

What does this all mean, then?  It means that, if hospitals truly want to prevent and mitigate patient violence at its roots, the focus of these efforts must shift to a clinical-focused strategy and away from a security-focused one.  Here are just a few examples of these clinical-focused efforts:

• Behavioral Emergency Response Team (BERT)- This is a multidisciplinary team that intervenes in situations where a patient requires de-escalation or proactive measures, such as a better medication strategy, an acute care plan, or more.  

• S.A.F.E. Response- A comprehensive, multidisciplinary program to prevent injury from violence using training, standardized interventions for clinical conditions affecting safety, and a clinical debriefing process.

• Project BETA - Project BETA (Best Practices in the Evaluation and Treatment of Agitation), Developed by the American Association of Emergency Psychiatry (AAEP) details guidelines for non-coercive, collaborative approach to managing acutely agitated patients based on on the best available evidence and expert consensus recommendations.

Don’t get me wrong, violence is a whole hospital issue that requires a collaborative, multidisciplinary approach with executive-level buy-in and visible support from the top.  However, the focus of the prevention and mitigation efforts must shift to evidence-based clinical strategies - like those noted above - that are implemented in collaboration and communication with security and other services.  

“Violence is a whole hospital issue.”

This approach aligns with my recent article advocating for the development of a Safety from Violence Officer (SVO) role to lead workplace violence prevention and mitigation efforts.  A clinical-led, multidisciplinary, evidence-based approach to tackling the growing issue of violence is not as easy or as quick as adding cameras, panic alarms, and extra security coverage, but the payoff for staff and patient safety is sure to be much greater.  

What are your thoughts about this approach?  I’d love to hear from you.

3 Signs You’re Getting Security Wrong at Your Ambulatory Practice

Photo Credit: Martha Dominguez de Gouveia

Many ambulatory practice leaders don’t think much about the physical security of their site until something bad happens, until there’s a near-miss, or when they hear about a tragic incident in the news that hits home.  At that point, it may be too late- staff now feels unsafe, they have lost trust in their leadership to be proactive about security, and knee-jerk security changes may seem like placating measures only. 

So why wait until there’s a problem?  Well, for many ambulatory sites, violence doesn’t occur at the same rate as it does on hospital campuses.  When it does happen, it’s often verbal abuse, intimidation, and other, non-physical forms of violence, unlike in hospitals where escalation to physical violence is more common.  But the psychological harm of verbal abuse, threats, and intimidation from patients, their family members, and co-workers should not be underestimated.  I have seen the damage that this can inflict on staff as both a security director and as a consultant. 

Clinical staff cannot render excellent patient care when they are in fear for their safety in their own office and your front office staff can’t provide great customer service when they’re afraid of who is going to come through the front door next.  This erosion of the feeling of safety and security in the workplace can be detrimental to the practice as a whole- impacting patient care, staff morale, and turnover. 

So what are three signs that you’re getting security wrong at your practice?  Let’s take a look:

1. Your staff have little to no training in security and de-escalation.  Empowering your staff through a de-escalation program tailored to the ambulatory/outpatient setting is one of the best, most cost effective ways to help staff feel safe at their workplace.  Think about it- most ambulatory sites don’t have the luxury of security staff who can be called and quickly arrive to assist in escalating situations and the police are usually several minutes away.  Staff are responsible for their own safety and they know it.  Leaving them without the training and the skills to recognize when a situation requires de-escalation, avoid dangerous situations and when and how to get help is a recipe for disaster.  A lack of time for training is no excuse.  Practice administrators inevitably will find time for training when an incident has already occurred, but by then the psychological (and sometimes physical) damage from the incident has already been inflicted.  

2. There’s no access control between the waiting area and the treatment area.  I can’t tell you how many times I’ve seen the door from the waiting area to the treatment area left unlocked or propped open in ambulatory practices.  It’s a common mistake that virtually eliminates the control that your staff have over who enters the treatment area of your practice.  If Mr. Jones, your medication seeking patient comes in and wants to see his doctor right now, how are you going to stop him from finding her?  And if Mrs. Smith wants to give your nurse a piece of her mind for the conversation they just had over the phone, how do you stop her from entering?  The answer is that you can’t!  Simply locking the door between your waiting room and the treatment area is an important step.  However, you need to be sure that the locking method is easy to use and that staff are on board with it.  If you require your staff to fumble with keys to get in the door every time or there’s no door closer to ensure it shuts after each entry, you’ll quickly end up with an open or unsecured door.

3. You don’t plan in advance for difficult patients.  Every practice has difficult patients regardless of the quality of the care team and practice.  Some patients are demanding, some are threatening or verbally abusive, others are unhappy with their treatment.  In many cases, you’ll know when a difficult patient is coming, when you need to give some bad news to someone who might react poorly, or when you need to set limits with a patient.  It’s important to trust your gut instincts and the instincts of your staff when it comes to these patients and plan ahead for their visit.  Develop a plan A, plan B, and maybe even a plan C for various scenarios that may unfold with the patient.  Designate who will do what and when.  Don’t forget to inform all staff in the practice about the plan.  For example, if your nurse standing outside the exam room of the difficult patient hears yelling and tells the front desk receptionist to call the police, the receptionist should know what the situation is and why they need to call already.  Don’t wait for the you-know-what to hit the fan before making a plan on the fly.  And don’t talk yourself out of what your gut is telling you about the potential risk that the patient poses.  

There you have it- three signs you’re getting security wrong at your ambulatory practice and how to mitigate these issues.  None of these issues are costly to implement- they just require a small financial and time investment and some ongoing planning and assessment.  So, why wait?  

This Is The Most Important Tool for Violence Prevention at Ambulatory Sites

Sarah had a bad gut feeling about the patient she was about to see. However, as a provider in a small primary care practice, she felt compelled to see the patient regardless of her own concerns about her safety. After all, what other options were there?

She started thinking about the worst-case scenario and then tried to think about how she might protect herself if things got out of control. All of these thoughts just made her more anxious than she already was, so she stopped. The patient, James, a large and often intimidating presence in the practice, was waiting in an exam room, talking loudly on his cell phone.

As soon as Sarah stepped into the room, he got up from his chair and cornered her, finger in her face, demanding that his medications get refilled “or else”. Sarah tried to get around him, but she was trapped. She yelled for help and her fellow staff members came to her aid. James backed off and stormed out of the exam room and the practice, yelling, “if I have to come back, you’ll be sorry.”

What might sound like a dramatic example of a medical drama playing out on TV is all too real for medical professionals and support staff working at ambulatory and outpatient care sites. Whether they are working at an outpatient surgical center or a small family practice, the staff at these sites have found that they are not immune to the increase in frequency and severity of violence happening at larger medical centers and hospitals. In fact, these ambulatory and outpatient care sites are even more vulnerable than their larger counterparts due to the lack of support they have in terms of security resources.

Even when these locations are part of a larger hospital or health system, their sheer numbers, geographic diversity and other factors make them hard to fold into the larger institution’s often limited security program. This leaves the sites with little to no professional security assistance, no one to come running around the corner to help staff when patients lash out, no one to assess threats and the patients who make them. That’s right- the staff are on their own to serve as their own security staff and to do their best to manage patients who are potentially violent.

Sounds pretty concerning, right? Well, in many cases, the folks who work at these sites do an amazing job handling problematic patients with their limited resources. They sometimes have the advantage, in a small family medicine practice, of knowing the patient for a long period of time, knowing their other family members, or both. The historical knowledge of these patients can certainly put behaviors in context as well as provide an idea of what could potentially de-escalate the patient based on what worked in the past.

However, in many settings, patients may have a limited history with the practice and the threatening behavior can be new, hard to predict and can frighten the subject of the threats in addition to the other staff working in the practice. No matter the specialty, affiliation, or the location of the ambulatory or outpatient site, patients will inevitably bring their expectations, history, and problems with them when they arrive for their appointment.

I have found, in my work as both a Security Director and as a Healthcare Security Consultant, that many staff working at outpatient and ambulatory sites feel generally safe. However, there are situations where the entire staff at one or more of these sites feel quite unsafe and are just waiting for “the worst case scenario” to unfold. They work in a constant state of vigilance and concern.

For example, at one site I visited as a consultant, the staff had deployed vehicle emergency glass break hammers in every room with a window in their practice so they could smash out the windows and escape if someone started shooting. Imagine the staff in this practice- feeling so frightened on a regular basis by the patients they serve that they feel they need to take this measure.

So, what’s the solution to this problem? How can we keep our staff working at these remote locations safe? How can we empower them and equip them to handle situations with escalating, threatening and/or violent patients?

The answer is violence prevention and response training. It’s important to recognize that employees are their own first line of defense when dealing with a patient who is getting agitated, being verbally abusive, threatening, or physically violent. This is true in both large medical centers/hospitals and at ambulatory/outpatient sites. However, with ambulatory/outpatient sites without security staffing, employees are also the last line of defense before the police arrive (if they are even called).

All staff – from the ones who feel safe to the ones who feel frightened - have one thing in common - they want training and tools to keep themselves safe in case there is an incident with an escalating, threatening or violent patient. Providing practice staff with the training to identify when things are beginning to go downhill with a patient’s behavior and how to respond to what may come next empowers them to take their safety into their own hands. Proper training can also reduce fear and anxiety in staff when dealing with these situations since they are equipped with the proper tools in their toolboxes to keep themselves and their fellow employees safe.

Sounds like a good idea and easy to pull off, right? Wrong. The biggest challenge that these outpatient and ambulatory sites face is that, due to them being scattered around one or more geographic areas with limited staffing, they can’t just all close up shop and gather in a big conference room somewhere for training. Even trying to get a training set up inside each practice is logistically difficult with the challenge of getting everyone on their lunch break to be in the same room at the same time for a training that may last an hour or more.

It’s not that these sites don’t want to provide their staff with violence prevention and response training, it’s that they have a very hard time pulling it off with their inherent logistical challenges. For these reasons, it’s not uncommon to see only some staff across multiple practices operated by the same system trained on how to recognize and respond to violence. In some cases, none of the staff are trained.

So, assuming a practice can pull off a training on a limited or widespread basis, what elements should the training contain generally? With time and other logistical constraints, the training should be right to the point and address the most common types of situations that staff may encounter. Here’s a general outline of topics that should be covered:

-Workplace Violence Overview: The definition and overview of the risk violence poses in healthcare.

-Preparing for Safety: How to prepare your mind and workspace for potential violence.

-Recognizing Aggression: The warning signs that someone may become aggressive.

-Responding to Aggression: How to de-escalate someone who is upset or angry and how to keep yourself and others physically safe if things get out of control.

-Threats: How to respond when direct or implied threats are made in person, by phone, or electronically.

-Preparing for Difficult Patients and Giving Bad News: How to plan for safety when there’s a difficult patient expected in the practice and how to plan for giving bad or upsetting news to a patient who may become volatile.

-When and How to Involve Law Enforcement: When and when not to involve law enforcement and the best ways to get the response and help needed.

-Arriving at and Leaving the Workplace: How to stay safe when coming to and going from work in the parking lot and before/after normal business hours.

-Basic Evaluation of The Workspace for Safety: How to perform a basic evaluation of the safety of each employee’s workspace from the violence prevention and response lens.

In addition, running staff through some scenarios by just talking through their responses to a variety of realistic situations with the potential for violence is also quite helpful in allowing staff to mentally apply the training concepts outlined above. It’s important to note that this training, like any other training, should be repeated, in some form, on a regular basis- every 1-2 years to keep staff fresh on key skills and techniques.

In closing, one of the most powerful and empowering tools that can be leveraged to keep staff at ambulatory and outpatient sites safe is violence prevention and response training. Staff are on the front lines every day and they are their own first line of defense. However, for training to be effective, you need the right lessons to be delivered on a realistic and repeatable timeline.

Wrapping in scenarios helps staff to think through how they might handle a threatening or violent patient in their practice and helps to mentally program them to prepare for these situations. Overall, trained and empowered staff are safe staff. They will feel cared for when they have the right training to keep themselves, their colleagues and patients safe. When this happens, everyone in the practice can focus on the number one priority- providing the best care for every patient who walks through the door.