HCWs risk workplace assault, report states
NIOSH recommends prevention strategies
An 80-year-old man entered a hospital in Washington state seeking assistance, but when he felt he was not getting the attention he deserved, he suddenly drew a sword that had been sheathed in his cane and cut off the finger of a receptionist.
Such anger- and frustration-related incidents of violence against hospital workers have been growing in frequency during the last decade. In fact, a recently released report by the National Institute for Occupational Safety and Health (NIOSH) states that health care workers are at greatly increased risk of nonfatal assaults in the workplace, with 11% of all nonfatal workplace assaults nationwide in 1992 occurring in hospitals. The source of injury in 45% of cases was a health care patient.1
Lynn Jenkins, MA, a NIOSH senior scientist and author of the report, says the document is part of the agency’s ongoing effort over the past 10 years to collect and disseminate data on workplace violence. The report, which covers a broad spectrum of work settings in addition to health care, lists risk factors and prevention strategies but does not recommend any single means of protecting workers from violent acts.
"There is very little empirical evidence about what works in different settings, but we know for certain that there is no one strategy that will work in all settings, not even in all health care settings," Jenkins tells Hospital Employee Health. "What is appropriate will differ from site to site."
Jenkins suggests that hospital officials investigate actual or potential incidents of violence in their facilities and design a program that addresses those situations, "whether they be [caused by] visitors coming in from the outside, people waiting in the emergency room, or problems in the psychiatric ward. The real message is that this is an important problem, here are the data about it, now we need to look at all of our workplaces especially those that have high risks and figure out what works in that setting."
Workplace violence has become such a serious issue in health care facilities that the U.S. Occupational Safety and Health Administration (OSHA) recently issued voluntary guidelines for protecting HCWs. (See related story in HEH, October 1995, pp. 125-128, and August 1995, pp. 104-107.) Calling violence in the health care industry "endemic," the OSHA document stated that HCWs are at risk for both fatal and nonfatal assaults.2
The NIOSH data on nonfatal assaults include only those injuries that were severe enough to require days away from work. Assault incidents included workers being knocked to the floor or against a wall, being shot, stabbed, raped, beaten, kicked, hit, scratched, pinched, squeezed, or threatened with violence.
"This is a serious problem, and we all need to take it seriously," says Jenkins, who adds that violence against HCWs is not just a big-city or inner-city problem.
Establish zero tolerance for violence
"I would not suggest that hospitals in small towns neglect this problem entirely and think it is a problem that won’t affect them, because we all have to be prepared for the reality that it could affect us," she notes. "We must establish the expectation that there is zero tolerance for threats and violence that they are not acceptable behavior and have a plan or procedure in place to deal with threats while they are still threats."
According to the NIOSH report, factors that increase an employee’s risk of workplace assault include many that apply to HCWs: contact with the public, delivery of services, working with unstable or volatile people, working alone or in small numbers, working late at night or during early morning hours, working in high-crime areas, and working in community-based settings.
Recommended prevention measures are grouped in three categories: environmental designs, administrative controls, and behavioral strategies. While some may seem extreme or inappropriate to health care settings, Jenkins notes that they are intended for a variety of workplaces, and that hospital officials must consider only those strategies that seem appropriate for their institution.
• Environmental designs.
Physically separating workers from the general public with bullet-resistant barriers or enclosures, or counters that are high and deep enough to introduce physical distance between workers and potential attackers.
Making high-risk areas visible to more people and installing good lighting.
Limiting and safeguarding entrances and exits through which non-employees can gain access to work areas.
Installing security devices to facilitate identification and apprehension of perpetrators, such as closed-circuit cameras, two-way mirrors, alarms, card-key access systems, and panic-bar doors locked from the outside only.
Using personal protective equipment such as body armor, similar to the bulletproof vests police officers wear.
• Administrative controls.
Using staffing plans and work practices, such as escorting patients and prohibiting unsupervised movement within and between clinic areas, increasing the number of staff on duty, having security guards or receptionists screen people entering the workplace, and controlling access to actual work areas.
Establishing policies and procedures for assessing and reporting threats, including guidance on recognizing the potential for violence, methods for defusing potentially violent situations, instructions on using security devices and protective equipment, and procedures for obtaining medical care and psychological support following violent incidents.
• Behavioral strategies.
Training employees in nonviolent response and conflict resolution and the hazards associated with work tasks and work sites (including relevant prevention strategies).
Emphasizing appropriate use and maintenance of protective equipment, adherence to administrative controls, and increased knowledge and awareness of workplace violence risks.
The first priority in developing a workplace violence prevention program is to establish a system for documenting violent incidents, the NIOSH report states. Data are essential for assessing the nature and magnitude of violence, for quantifying risk, and for implementing reasonable intervention strategies.
A written workplace violence policy should be developed, along with a "threat assessment team" to which incidents of violence and threats are reported. The policy also should include procedures to be followed in violent events.
Stress plays a part in workplace violence, both as a cause and an effect. Violent incidents lead to stress among workers, "perhaps even to post-traumatic stress disorder," and high levels of stress can cause violent incidents in the first place, the report notes.
High levels of stress, resulting in anger and frustration at not getting the desired service, can lead even "normal" people to react violently, as did the 80-year-old man, says Michael S. Stultz, CHPA, CPP, director of security at Sacred Heart Medical Center in Spokane, WA, and past president of the Chicago-based International Association for Healthcare Security and Safety (IAHSS).
"The general anger level of people is much higher today. People come into a hospital and feel they are not being treated well, that they are not getting the help they need, and they react with anger and frustration," Stultz says.
HCWs feel the strain
Even health care personnel are beginning to "crack" under the pressure of dealing with people who are "so disrespectful, so profane, and so demanding," he points out, noting that incidents of physicians, nurses, and even security personnel assaulting combative patients are on the rise.
Each year, the IAHSS conducts a crime survey of U.S. and Canadian hospitals. Some 280 hospitals participated in the 1994 survey, the most recent year for which data analysis is available. The survey shows continued growth in crime, ranging from homicide to vandalism, among both urban and suburban hospitals. Rural facilities have nearly the same ratio and rate of violence against workers as do inner-city hospitals.3
The number of physical assaults was higher in 1994 than during the last eight years the survey has been conducted, with 5.63 per reporting hospital in 1994 compared with 5.13 per hospital on an eight-year average. (For a breakdown of data relating to assaults, see chart, p. 142.) Sexual assaults also registered a large increase (61.5% over the average of the previous five years), with employees being the victims in 39% of those assaults.
Overall, hospitals participating in the 1994 survey reported 20,254 crimes occurring on their premises, resulting in more than $5 million in losses. Employees were the victims 37.2% of the time, making them the largest population of health care crime victims, according to the survey.
The IAHSS report also points out that for the first time since the survey began, inner-city hospitals reported less than 50% (45.6%) of the total crimes in 1994, which is "a good indication of the growing pattern of crime in the suburbs and rural areas of the nation."
High rates of illegal drug use and drug dealing are occurring even in hospitals, Stultz tells Hospital Employee Health, which contribute to violence. In fact, violence within hospitals "mirrors the disintegration of society in general," he points out.
Hospital employees often are victims of violence because they’re trained incorrectly, Stultz adds.
"They have been trained that it is okay to get hit and hurt as part of the job, that they’re there to treat patients, and if patients get out of control it’s okay because they’re patients," he states. "We’ve set up [HCWs as victims] by the psychology of how we teach them to take care of themselves. We have to teach them social accountability, which means that if the same behavior we would not tolerate on the street occurs in the hospital, then perpetrators must receive the same punishment for it, with the exception of [violent] geriatric patients who really don’t know what they’re doing."
HCWs must be taught to understand the cycle of violence, "what causes it, where you can intercept, and how you can calm people down instead of reacting and making it worse," he adds. "Aggression management is almost a required class for health care workers now."
Security measures vary among hospitals according to need, but Stultz says that facilities located in moderate- or high-crime areas should consider closed-circuit TV and panic alarms at the very least.
"We are forced by the economics of health care to provide protection for staff and patients," he says. "If something happens at your facility you’re sued, you’re dead."
[Editor’s note: To obtain a copy of the NIOSH report, contact Publications Dissemination, EID, NIOSH, 4676 Columbia Parkway, Cincinnati, OH 45226-1998; telephone: (800) 35-NIOSH; fax: (513) 533-8573; e-mail: [email protected]. To be referred to an expert health care security consultant in your area, call the IAHSS at (708) 953-0990.]
References
1. U.S. Department of Health and Human Services. National Institute for Occupational Safety and Health. Violence in the Workplace: Risk Factors and Prevention Strategies. Current Intelligence Bulletin 57. DHHS (NIOSH) Publication No. 96-100. Cincinnati; 1996.
2. U.S. Occupational Safety and Health Administration. Guidelines for Workplace Violence Prevention Programs for Health Care Workers in Institutional and Community Settings. Washington, DC; 1995.
3. Stultz MS. Crime in hospitals 1994 the latest IAHSS survey. J Healthcare Protection Management 1995; 12:1-48.
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