While nearly every hospital nationwide now has a plan in the event of an Ebola patient, few are prepared for a workplace threat that is becoming all too common: an active shooter or another kind of violent act.
Healthcare workers are about four times more likely to be injured from workplace violence and need time away from work than all workers in the private sector combined, according to 2013 U.S. Bureau of Labor Statistics.1
Brigham and Women’s Hospital in Boston, MA, was the tragic site of an active shooter scenario in January when a middle-aged man walked into the hospital and shot the cardiothoracic surgeon who had treated his mother. The surgeon died, and the shooter then killed himself.
The danger could have escalated and worsened if it weren’t for active shooter training the hospital had begun a few years earlier, says Leonard Marcus, PhD, lecturer on public health practice, department of health policy and management, Harvard School of Public Health in Cambridge, MA.
Still, the question many hospital employee health professionals might ask is “How can we help to prevent active shooters and violence in our hospitals?”
The first step is for employee health leaders to become actively involved in any emergency preparedness scenario that includes violence and to collect accurate information about violent acts against workers, says James Blando, PhD, an assistant professor at Old Dominion University College of Health Sciences in Norfolk, VA. Blando has researched the issue, recently publishing a study about the barriers to programs preventing workplace violence.
Staff should report every incident — no matter how they might rationalize it, he says.
“The first barrier to preventing violence that we identified is underreporting of workplace violence,” Blando says. “A lot of hospital staff told us that if you’re really busy in health care, you don’t feel motivated to fill out more forms.”
This was especially true if they had reported previous violent acts, and nothing happened, he adds.
Violent acts unreported
Research has found that more than two-fifths of physical violence in hospitals is not reported.2
Employee health leaders could help promote a better reporting system and advocate for higher security spending, noting the financial benefits of making the workplace safer, including higher productivity, lower turnover, and less employee stress, Blando says.
“If employees don’t feel secure, they’re less productive,” he adds. “Security in my view is a good investment, and studies clearly show that.”
Another strategy for preventing violence and active shooter events is to put ample resources into well-trained campus security, Blando says.
With a brief literature review, employee health leaders could gather evidence about the benefits of enhanced security to present hospital decision-makers.
“What we found is violence in hospitals and the rate at which employees were injured was much more related to the security budget than to the crime level outside the hospital,” Blando says. “That was a fascinating finding.”
Blando and investigators found that hospitals with serious community crime problems, including gang violence, had an appreciation for good security and invested in top notch security. They also developed good relationships with local police and sometimes had tight security at entrances, requiring visitors to obtain a visitor’s pass that would be the only way to enter corridors or operate elevators. They’d also check to make certain that visitors named an actual patient before giving them admission to the hospital.
“The hospital might be in a terrible area, but it had a very low assault rate,” he says.
By contrast, researchers studied hospital violence in a rural area where there was very little community violence and found that there was a higher assault rate in the hospital.
“A lot of hospital chief executive officers would say to us, ‘I don’t need a strong security program – it’s beautiful outside and there’s farm land, why do we need to spend money on a security program?’” Blando recalls. “What one hospital CEO didn’t know was that he had a security guard who had his neck broken from two guys having a fight in the emergency room after their dad was brought in for a heart attack.”
The underpaid security guard was elderly and tried to intervene when he was knocked down and a vertebra in his neck snapped. At another rural hospital, a nurse was raped on the job, Blando adds.
“All of those things precipitated with the idea that ‘We don’t have a problem in this hospital,’” he says.
Strong security sends a message to staff that the hospital is safe, as well as to potential perpetrators that they might not be able to get away with something in this setting, Blando says.
Another strategy involves teaching hospital staff how to handle an active shooter or other violent encounter.
“It’s impossible to prepare for every event,” Marcus says. “Therefore, using an all hazards approach and identifying key risk factors provides opportunities to invest in strategies training, which are scenarios hospitals might confront.”
For instance, Brigham and Women’s Hospital had earlier developed a training video about an active shooter scenario, Marcus notes.
Training similar to actual incident
“It’s extraordinary that the training video’s scenario was almost exactly the scenario that actually occurred, which was having an angry individual with a gun going into the very building [featured in the video],” he says. “When the event occurred in Boston they were ready to go into immediate preparation, and everyone knew what to do.”
The video advises employees to run, hide, and fight, with an emphasis on running and hiding. Fighting is only a last resort when cornered.
However, this approach when it comes to a shooter is controversial and not evidence-based, says Michael Dorn, executive director of Safe Havens International of Macon, GA.
Dorn is a former police chief who has been in multiple active shooter situations and has trained police, schools, hospitals, and others how to handle them.
“We do a lot of security assessments, including simulation,” Dorn says. “Our film unit recorded 80 different crisis situations, and we found that people who have seen that video respond worse than people who don’t see anything at all.”
With some training programs, people move to fight when it’s not the best option, so employee health leaders should be cautious when selecting a strategy for training staff, he says.
“Close quarter combat can’t be boiled down to a 10 minute video,” he says.
The best preventive strategy is to bring together hospital leaders, local law enforcement, and mental health experts to share ideas and develop a plan or discuss particular situations, Dorn says.
“Get different viewpoints and evaluate situations where someone has made some kind of communication, written down something or put something in social media or had behaviors that people find concerning,” he advises.
Although an FBI study released Sept. 24, 2014, identified 160 active shooter events, killing or injuring more than 1,000 people, between 2000 and 2013, active shooter violence is still less likely than other types of violence, Dorn says.
“Twice as many people are beaten to death with hammers and other blunt objects than were killed by rifle fire,” he notes.
In addition to staff training and increased security presence, metal detectors — at least in the emergency department — are a good option, Blando notes.
Few hospitals have metal detectors, often citing concerns about creating a less inviting environment for patients and visitors, Blando says.
“But the few studies that do exist show that use of metal detectors in an emergency department is appreciated by patients and families when there is proper explanation,” Blando says. “They felt it made them safer, so that’s what we would argue to management — that this is really useful in a security program and good customer service.”
- Nonfatal occupational injuries and illnesses requiring days away from work, 2012. Bureau of Labor Statistics. 2013; Publication #USDL-13-2257: http://www.bls.gov/news.release/pdf/osh2.pdf.
- Blando J, Ridenour M, Hartley D, et al. Barriers to effective implementation of programs for the prevention of workplace violence in hospitals. OJIN 2015;20(1): http://bit.ly/1Ea03z4