By Dorothy Brooks
Workplace violence continues driving some skilled and valued healthcare workers away from professions they long trained to join. Some believe this problem never will end.
In 2021, researchers reported 77% of ED staff said they were exposed to violence at work.1 However, there is evidence suggesting some health systems are making gains against this scourge. These leaders are sharing their roadmaps and best practices so others can benefit.
Inova, a health system based in Falls Church, VA, and Trinity Health, a health system based in Livonia, MI, have made significant progress toward improving staff and patient safety. For both systems, the effort has required top-level support and several initiatives that attack the problem from different angles. Data show these systems are making a sizable dent in incidents of violence in their EDs and other vulnerable points.
In 2021, Inova tackled the issue with a multipronged effort that encompassed several distinct initiatives. However, one of the approaches, which maintains high visibility to staff, is the deployment of special teams that respond to alerts whenever and wherever staff feel their safety and/or patient safety might be threatened.
The Safety Always for Everyone (SAFE) teams typically consist of an administrative director, at least two security guards, an admitting hospitalist, and either a unit supervisor or the charge nurse who is on staff in the affected unit, explains Zach Wotherspoon, DNP, APRN, FNP-BC, RN, senior nursing director of emergency services at Inova Alexandria Hospital in Stafford, VA.
“When there is a concern about somebody who is escalating, whether that be because of a medical or a behavioral health reason, we like to call a SAFE team alert in order to get all the resources to that patient in a timely manner,” Wotherspoon explains. “Our goal is to respond in less than 10 minutes, but it is usually must faster than that — within two or three minutes.”
During this multidisciplinary response, each SAFE team member can evaluate the situation, work through the care plan, and adjust as needed. For example, staff want to establish whether there is a purely behavioral health issue or a physiological issue. Perhaps the patient’s physical health status has changed or deteriorated, leading to poor behavior or aggression. “From there, the administrative director will escalate the case to executive level management, senior management, patient relations, patient experience, the chaplain, risk management, ethics, or the administrator on call, as needed,” Wotherspoon says.
For instance, it is not unusual for patients who are withdrawing from alcohol to visit the ED. “You know they are at risk for physiological and behavioral health issues related to that withdrawal. We have protocols that we place these patients on to help prevent them from escalating,” Wotherspoon says. “However, occasionally, despite going through those protocols and processes, there is still a need for further intervention ... putting in a call to the SAFE team is a way to ensure that the practitioners are there and can adjust the treatment plan accordingly, along with supportive security.”
All SAFE team members complete Crisis Prevention Institute training to ensure they are skilled on how to most effectively de-escalate tense or aggressive situations. “We have done mock SAFE team alerts as well to make sure that new team members are familiar with the process,” Wotherspoon notes.
Another innovation that has been particularly helpful is the addition of behavioral health officers. These security officers have completed additional training in how to interact with behavioral health patients in a safe and non-escalating manner. Their role is to look for opportunities to defuse potentially violent situations before they escalate. For the sake of staff’s psychological health, Wotherspoon calls this innovation “a huge win.”
Further bolstering psychological safety are weapons detection systems that have been implemented in all Inova EDs. “Everybody coming in through the front door passes through these systems that are programmed to detect firearms and knives. We have a process by which security will ensure that weapons are not being brought into the facility,” Wotherspoon says. “These systems have created a sense of safety and security — not only for the staff, but also the patients.”
Inova’s efforts to bolster safety are producing results. Along with encouraging staff to report incidents of violence, administrators indicate there has been a 60% reduction in violence in the health system’s EDs since 2021. Wotherspoon says the improvements also have translated into lower costs from workers’ compensation and related expenses.
However, work remains. For instance, Wotherspoon notes there still are too many emergency clinicians who consider violence as just part of the job. He acknowledges this “deeply rooted” cultural stance will take time to change.
Nonetheless, Inova has incorporated workplace violence into the daily conversation, ensuring all its initiatives in this area are multidisciplinary.
“It’s a win/win when you’re looking at different pieces of the puzzle by way of nurses, EMTs, physicians, and security,” Wotherspoon says. “Everybody has a different outlook inherently on workplace violence events and on what their duty is in response to those incidents. Without a common dialogue and a common goal, you’re not going to make progress on safety.”
Tyler Kerns, MC, LPC, national chairman for Trinity Health’s violence prevention steering committee, agrees that effective violence prevention in healthcare requires interdisciplinary expertise. He spoke about his experience with Trinity Health System’s efforts in this regard at a presentation put on by National Action Alliance to Advance Patient Safety and the CDC on June 27.
“We incorporated safety as one of our core values in 2020, and we really view our colleagues’ safety and our patients’ safety as one. These are fully integrated, and our strategies and teams collaborate to make sure that they support and bolster one another,” said Kerns, a violence prevention and education consultant at Saint Alphonsus Regional Medical Center in Boise, ID.
Trinity implemented a way to regularly identify where health system employees face risks regarding workplace violence. The Brøset Violence Checklist (BVC), a brief assessment tool that helps predict violent behavior, was integrated into the health system’s electronic medical record (EMR).2 “This has become a standard workflow item [to] identify patients who may be at greater risk of violence in the next 24 hours,” Kerns noted. “We’re doing this during triage and intake, both in the emergency department and the [inpatient] setting. If we have an interdisciplinary inner-agency transfer, we’re screening patients at that point as well.”
Along with the BVC, Trinity has integrated into the EMR a list of safety interventions that correspond with the acuity or risk level denoted by the BVC score.
“We’re not only identifying where there might be an increase in risk, we’re also building into the process pre-emptive strategies to help mitigate [or prevent] there being an incident,” Kerns said.
Similar to the Inova SAFE team alerts, Trinity uses a “Code Safety,” which prompts a response by security, leadership, and clinical support to the scene of a threat. Leaders examined what happened, what led to it, and how to prevent future incidents. Clinical coordinators help attend to any injuries and work with colleagues to document the event. “Having a quality response in real time to that incident of workplace violence improves reporting, and it improves employee engagement so [staff members] feel like their safety truly matters,” Kerns said.
Kerns noted the Code Safety response has led to an uptick in reporting from the frontlines — not just of OSHA-recordable injuries, but any violent incident or attempted violence, even if there are no injuries. This has enabled Trinity to better understand where there are issues that need to be addressed.
In addition, Kerns explained several Trinity sites have piloted data-tracking approaches and dashboards they fully intend to expand across the system. “This will allow us to better stratify and analyze the data by date, by location, unit, type of incident, and severity, including all the way down to the job role of the colleague that was impacted by the event,” Kerns said.
Trinity sites are posting signage to communicate to the public that violence will not be tolerated. These posters specify behaviors that are considered inappropriate, sending the message that safety is a priority, and that patients are in a healing environment. Kerns also noted Trinity is working on a patient code of conduct to clearly outline what patients can expect from their providers, and what providers can expect in return.
Trinity’s comprehensive approach to workplace safety is paying dividends. The health system has seen a decrease of 37.7% in workers’ compensation tied to workplace violence. Leaders also have seen a drop in lost workdays. “This comes from having a big picture perspective to where we are looking at this from all angles,” Kerns stressed. “This is not just a security responsibility. This is going to take all of us.”
REFERENCES
1. Aljohani B, Burkholder J, Tran QK, et al. Workplace violence in the emergency department: A systematic review and meta-analysis. Public Health 2021;196:186-197.
2. Woods P, Almvik R. The Brøset violence checklist (BVC). Acta Psychiatr Scand Suppl 2002;103-105.
Two health systems have started several initiatives that attack the problem from different angles. Data show these systems are making a sizable dent in incidents of violence in their EDs and other vulnerable points. These leaders are sharing their roadmaps and best practices so others can benefit.
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