By Melinda Young
Healthcare workers are more likely to experience on-the-job violence than police officers. The healthcare field is four or five times more dangerous than any other profession. Violent attacks against physicians, nurses, and other healthcare professionals are on the rise.1-3
The deadliest attacks involve active shooters. In the past two years, men wielding guns killed a security guard at a Portland hospital, two workers at a Dallas hospital, one woman in an Atlanta medical center waiting room, and four people at a Tulsa, OK, medical office.1
The American College of Emergency Physicians polled members in 2022 and found two-thirds of ED physicians reported assaults in the past year. More than one-third said they had been assaulted more than once.2 Eighty-five percent of physicians said they experienced anxiety, emotional trauma, and a loss of productivity due to violence.2,3
The violence includes active shooter scenarios, although the more common types of violence involve verbal abuse and intimidation, discrimination, sexual harassment, stalking, and physical assault.3
Facilities may not be able to end violence, but there are many tactics they can implement to alleviate risk for employees and patients — particularly in the case of gun violence.
“I don’t believe there would be any way you could stop it. The idea is to train ahead of time so you know what to do,” says Ron Frederick, director of safety and security at Service Access & Management in Pottsville, PA. Frederick is scheduled to speak about safety training at the National Association of Case Management Annual Conference, Oct. 3-5, 2023, in New Orleans. “In Pennsylvania, all of our police departments have been trained on active shooters and will come to your facility and do training for you. Training is the most important part.”
Healthcare organizations should spend resources on training and protection because these can save lives. This is important even if its outcomes are not quantifiable in data.
“Everyone is data-driven, and there need to be statistics for everything,” Frederick says. “You may never know what you may have stopped ahead of time.”
Frederick offers these suggestions for protecting and preparing staff for active shooter events:
• Look for exits and other tactics. Everyone in a workplace setting should take note of their alternative exits to any space.
“These are not just normal exits,” Frederick explains. “Think about it when sitting at your desk: ‘What would I do if the situation arose right now? How would I get out of here? How would I protect the patients I’m serving?’”
Healthcare facilities should hire the right kind of security guards. They need people who are physically and mentally alert and prepared to identify a shooter and act to save lives.
Hospitals are a small community where issues constantly occur, especially in the ED. Security guards should be prepared to handle these issues, Frederick adds.
• Train staff and hold drills. The single most important thing case managers and other healthcare professionals can do is participate in training and running drills.
“Go through different scenarios and hands-on training — the same as they do for schools,” Frederick says. “Everyone should be doing this type of training.”
For example, hospitals could use a conference room for the training so it does not interfere with patient care. Or, if training needs to be in a specific area, such as an operating room, then it could be conducted at an hour when there are no scheduled surgeries.
Training should be performed once or twice a year, with no more than two years between sessions, Frederick advises.
The goal is to teach a person to act safely without thinking about it or without panicking. If someone has only been through one round of training, they might panic before acting when confronted with an active shooting situation.
“If it’s a muscle memory thing, you will revert to that,” Frederick says. “That’s why SWAT teams train constantly. As a former SWAT member, you don’t even think about what to do when it’s happening — you revert back to your training. It would be the same thing in this situation.”
For example, students present during the Oxford High School shooting in Michigan said they remembered their active shooter drills and quickly barricaded doors with desks and chairs, covered windows, and hid in corners or bathroom stalls. Some even armed themselves with scissors and anything else they could find to use as a weapon.4
Also, training should be updated as new data and information become available about how these crises unfold. “We learned a lot from the Columbine school shooting, and the way police officers are responding has changed several times since then,” Frederick explains.
Healthcare settings also need to change as research provides more information about what works and what does not when staff are confronted with an armed and violent assailant. Training in schools has used the mantra of “Run, hide, fight.” But recent training focuses on these three sets of actions: avoid, defend, and deny, Frederick says.
To avoid a shooter, people should look for shelter in a place with filing cabinets, a locked door, and heavy furniture. The best room would have a way to barricade the door and furniture or equipment where people could hide with some ballistic protection. “Look for some place with decent cover,” Frederick says.
Defending against an assailant includes grabbing something that could be used as a weapon, as the Michigan high school students did. This could be a stapler, a computer, or anything that could be thrown at a shooter if the person approaches.
The “deny” tactic includes a facility remotely locking sections of a building. It also refers to keeping a room secure by making it too difficult for the shooter to enter.
• Plan for protecting patients. Some hospitals can section off rooms with glass partitions made with a bulletproof film. They also might include a place to hide patients.
Most of the time, individual hospital employees have protected patients in these situations by sheltering with patients in their rooms, locking doors, and not letting anyone in unless they can prove they are a police officer.
“What you can do, if you have communication to the outside, is call the 911 center and tell them your room number and have them give you a password that the officer has to say before you will open the door,” Frederick notes.
Healthcare professionals also can use their skills to keep patients calm during the crisis. Their training will have helped them stay calm themselves, and they can help the patient with meditation or a breathing exercise to alleviate their fear and prevent panic.
“Unfortunately, with these instances, you don’t know how you’ll react until it actually happens,” Frederick acknowledges.
• Act against shooter as a last resort. After most gun massacres, there are stories about one or more people who risked their lives or lost their lives when they attacked the shooter. This is not an action most people should attempt, but if all else fails to protect people from the shooter, this could be a last resort.
For example, if several people are sheltering in a room the gunman enters, they could work together to attack the perpetrator by throwing a fire extinguisher, coffee cups, laptop, or stapler at him. They also could scream and yell loudly because it breaks the gunman’s concentration and may slow his reaction time, Frederick suggests.
To protect oneself, use the acronym OODA — observe, orient, decide, act. “Look for something to throw, scream, grab a limb — whatever it may be,” Frederick says. “It’s only a last resort. I would never tell anyone to attack someone with a stapler, but if it’s a last resort, you have no other choice.”
• Observe behavior to identify potential attackers. Large corporations sometimes use resources to identify potential attackers long before an incident happens. They can use data about people with a grievance against the company, such as those who recently lost their job. Corporations track the person’s social media for signs of potential violence.
“One of the biggest things here is most of these attackers plan out their attack far in advance,” Frederick says. “After the situation happens, people will come forward and say, ‘I saw this.’”
There usually are signs, such as posted rants with violent language against a particular person or group of people. Some shooters have posted photos of themselves carrying weapons used in massacres or dressed in insignia from hate groups that promote violence. Some even share their plans with a person they know online. In those cases, many people saw the signs but did not recognize or take them seriously.
“The world we live in today is one where people have to pay attention to it,” Frederick says.
• Be aware of employee risk signs. For example, in a hospital setting, there may be an employee who has changed in appearance and starts coming to work late. The person may display signs of drug and alcohol use. These people need access to help and counseling through the human resources department.
There also might be an employee whose behavior and appearance may show signs of domestic violence. That employee is at risk — as are the employees’ colleagues — of an attack by a violent partner.
“The HR department needs an open-door policy to let people come in,” Frederick says. “If domestic violence spills over into the workplace, that’s a sign.”
This could be someone hearing a nurse on the phone with a spouse who is yelling at her, or maybe her partner shows up when she gets off work. They could be going through a divorce, which HR should know about.
“They can let employees know that they can talk with HR about whether they’re feeling unsafe in their home,” Frederick says.
If the organization recognizes signs of a problematic employee, family member, or patient, someone should monitor social media.
“In most cases, people are preparing for the attack for weeks in advance,” Frederick says. “It’s not something that just pops in their head.”
REFERENCES
- Boone R. Attacks at US medical centers show why health care is one of the nation’s most violent fields. ABC News. Aug. 7, 2023.
- American College of Emergency Physicians. Poll: ED violence is on the rise. August 2022.
- Charles S. Unsafe haven: The rise of violence against physicians in the workplace. MDLinx. April 26, 2023.
- Goldstein D. After Michigan killings, students praised shooter drills. But do they really work? The New York Times. Dec. 2, 2021.
The American College of Emergency Physicians polled members in 2022 and found two-thirds of ED physicians reported assaults in the past year. More than one-third said they had been assaulted more than once. Eighty-five percent of physicians said they experienced anxiety, emotional trauma, and a loss of productivity due to violence.
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