Sarayna McGuire, MD, an emergency medicine physician at the Mayo Clinic, is becoming one of the leading researchers in healthcare violence, after recently reporting about how this longstanding problem became worse during the pandemic.
As previously reported1 in Hospital Employee Health, the study revealed reported violent incidents against healthcare workers more than doubled during the COVID-19 pandemic in the Mayo emergency department. “Incidents of workplace violence at our ED increased during the pandemic, and there was a positive association of these incidents with the COVID-19 case rate,” McGuire and colleagues wrote.2 “Violent incidents increased overall during the pandemic (2.53 incidents per 1,000 visits) compared to the previous year (1.24 incidents per 1,000 patient visits).”
Another study3 led by McGuire revealed “the unique environment of the ED contributes to its propensity for violence: stress among patients, families, and visitors; long wait times and delays; crowding; unrestricted 24-hour access; low socioeconomic status; substance abuse; [and] patients with behavioral health issues.”
McGuire’s latest research is slated for upcoming publication, based on the findings of an anonymous survey of employees in 20 EDs in the Midwest. Among the 833 respondents, those with the highest rates of physical assault in the prior six months were ED security staff (79%), nurses (54%), and clinicians (36%), McGuire reported in preliminary findings.4
“That manuscript is under review right now, but we basically found that the entire team is impacted by violence, regardless of whether they’re respiratory therapists, housekeeping staff, phlebotomists, you name it,” McGuire says. “Even in the entire health system, everyone is impacted by violence.”
HEH asked McGuire to comment on her work in the following interview, which has been lightly edited for length and clarity.
HEH: Your study is one the first to document an increase in healthcare violence during the COVID-19 pandemic. Can you speak to the significance of that finding?
McGuire: We heard personal anecdotes from healthcare providers that they’ve subjectively felt an increase in violence during the pandemic. We really felt it was important to try to objectively show that, and that’s what this study does. [Previously], we published incidence of violence at our institution from a survey study before the pandemic hit, so we had that pre-pandemic data. We wanted to see if there was any change in self-reported incidents of violence. When we looked at violent incidents per 1,000 ED visits, they were lower pre-pandemic. We showed that the incidence of physical assault increased during the pandemic, particularly assault with bodily fluids. Staff reported that patients spit on them or coughed on them. People in law enforcement [also] reported that throughout the pandemic.
HEH: You noted many reasons for an increase in violence, including patient surges caused by COVID-19. The spitting and coughing suggest patients were trying to spread the virus, or at least instill the fear that they could. Is there anything else particular to the pandemic that could have contributed to violence?
McGuire: We can only hypothesize because there’s no way for us to really know. But we do know that other research has shown that the incidence of domestic abuse increased during the pandemic as well. In those studies, they also tried to hypothesize what might have led to that. Some of the guesses are increased uncertainty, fear, untreated mental health [issues], increased untreated substance abuse, and just significant anxiety with an overall situation that is just so unfamiliar and so stressful.
HEH: What drew your interest to researching violence in healthcare?
McGuire: I’m actually a former military police officer, so I have a background in violence. I naïvely thought, like the rest of healthcare workers, that I was leaving behind a career in violence when I entered medicine, and that’s not the case at all. Thankfully, I have experience and training in how to deal with conflict resolution and agitated individuals, but in medical school we don’t receive dedicated training [on that]. I don’t even recall violence being mentioned in medical school, and it’s very much something that you experience your first day as a medical trainee, once you graduate and you’re in residency, and it’s on-the-job training from there out. It’s something that I think is very important to continue to shed light on, because the entire team is impacted by this, and yet the entire team does not receive training on how to mitigate violence or how to anticipate it. There are very limited support networks in place once you do experience significant violence in your workplace.
HEH: It would seem to make sense to add some violence prevention training in nursing and medical schools.
McGuire: I think nursing probably receives the most training of any healthcare specialty. Most prior research has really focused on nursing because they’re on the front lines in the patient rooms, and they historically have been the focus of most violence mitigation strategies. But the research that we’ve done has shown that the entire team is impacted. We have housekeeping staff and secretarial staff reporting violence. Our institution has purchased a [violence prevention] training program. Nurse managers are starting first to be the trainers, but they’re actually going to work on training other disciplines within our department — other than nursing — which I think is really important.
HEH: Have you personally experienced some level of violence from a patient?
McGuire: Absolutely. I was kicked in the abdomen by an agitated, intoxicated patient when I was around 20 weeks pregnant. That was with all my past training to look out for these types of incidents and be prepared. I just happened to let my guard down in the room. If even a former military police officer can be a victim of violence in these situations, you can imagine someone without any training. I think it’s important to share that because it shows that any one at any time can be impacted by this. Yes, my child is perfectly healthy.
HEH: Historically, incidents of healthcare violence have been widely underreported. Can you comment on that?
McGuire: I think it’s multifactorial. That’s actually one of the things that we sought to identify with our most recent health system survey. In essence, we surveyed this huge cohort from an entire health system. We asked them why they did not report incidents, and the answers were across the board. First of all, it’s very time-consuming on a busy shift to even sit down and go through an employee incident report. The reports are so lengthy. You just don’t have the time for that. There’s also this continued thought from staff — myself included sometimes — that violence just comes with the job. That starts your first day in healthcare. If you’re in training and you witness the person you’re with — your supervisor or trainer — get verbally abused or assaulted in some way, and they just brush it off, then you kind of continue with that thought throughout your subsequent years that “Well, it happens to everyone and so it’s just something to be expected and nothing’s going to change.”
HEH: Would improved reporting systems help?
McGuire: There’s always concern for different ways to report. In our institution, we’re working on a more centralized, singular reporting system because people don’t know how to file a report — which is pretty surprising. Some of our respondents indicated that they report violence through the patient incident reporting system, which actually isn’t correct at all. There are different avenues to report, whether it’s through law enforcement, security, occupational health, your supervisor, and that gets very confusing for people.
HEH: Do some people hold varying definitions or perceptions of what constitutes violence?
McGuire: Yes, I have actually surveyed our local law enforcement officers and our ED staff, asking “Would you consider this hypothetical scenario to constitute a reportable crime?” The answers were just so disparate. Law enforcement did not agree with healthcare providers, and within the healthcare providers there was disagreement with law enforcement. Honestly, people don’t understand the environment of healthcare from the outside. That makes it difficult when you’re a healthcare provider and you file a report about a significant event you [experienced]. You might not get the type of understanding and response from an outsider, like law enforcement or a defense attorney, that you would expect. That, in turn, makes you less likely to file a subsequent report, unfortunately.
HEH: Do you think there are disincentives for healthcare facilities to address these problems, to have occupational violence reported publicly, forcing them to deal with public perceptions of danger in the facility or patient satisfaction scores dropping?
McGuire: I don’t. I can only speak for where I work. We really try so hard to capture the numbers, because we really want to mitigate future violence, using the baseline data. If we don’t have those baseline data to know the situation, the circumstances, the demographics, the underlying characteristics of the patient that caused whatever happened, it’s really hard for us to then find ways to mitigate future violence. In our institution, we are really trying to capture all events as much as possible through violence flags on patient charts, and encouraging all employees to report by making a centralized database for reporting. From the outside, one might think that it could be detrimental to patient satisfaction or to the way that the health system looks, but I think it really speaks volumes about an institution. It’s so much in their favor to really encourage the safety of staff, really want to know what’s going on within the hospital walls, to mitigate it from continuing to happen.
REFERENCES
- Evans G. Violence against HCWs increased during pandemic. Hospital Employee Health. April 1, 2022.
- McGuire SS, Gazley B, Majerus AC, et al. Impact of the COVID-19 pandemic on workplace violence at an academic emergency department. Am J Emerg Med 2022;53:285.e1-285.e5.
- McGuire SS, Mullan AF, Clements CC. Unheard victims: Multidisciplinary incidence and reporting of violence in an emergency department. West J Emerg Med 2021;22:702-709.
- McGuire SS, Finley J, Gazley B, et al. The team is not okay: Multidisciplinary violence in emergency departments across a health system. Ann Emerg Med 2021;78:S53.
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