“I had a patient break through the nurse’s station window and attempt to harm staff. He threw a computer at me and put hands on my co-worker. He missed me, but it was terrifying. I had dreams about it for a few weeks.”

This chilling description is from an emergency department nurse participating in a recently published study that collected subjective, firsthand comments about healthcare violence,1 which has been going on so long that the cliché “it’s part of the job” remains a prevalent mindset.

“We wanted to primarily take a qualitative approach,” says lead author Lauren Querin, MD, MPH, an emergency physician at UNC Medical Center in Chapel Hill. “Showing the numbers is one thing, but describing the experiences and the emotions involved makes it more [real]. A lot of us have conversations about these things, and just showing the numbers doesn’t really get to the experience that our team has on a daily basis.”

Although the pandemic is being bitterly fought in some areas, the efficacy of the vaccines foretells an eventual ending and aftermath that could include many changes to the healthcare system. Will the routine acceptance of violence in healthcare — most of it inflicted by patients and visitors on staff — finally be called to account?

“I think there is a lot of room for growth and change,” Querin says. “People are more receptive to these kinds of things. Now is the time to rethink the ways to prevent violence as we start rebuilding our systems.”

Healthcare workers (HCWs) worked without sufficient personal protective equipment (PPE) during the pandemic. There also is no official count of how many HCWs died from the virus. Thus, it is hard to argue with the contention that HCWs are viewed as expendable. (For more information, see the April 2021 issue of Hospital Employee Health.) Failing to address violent attacks would only compound this view. That said, preventing violence in healthcare is a complicated problem that requires multifaceted programs. These programs should include clear definitions, education, and a user-friendly incident reporting system. These are some of the new “elements of performance” requirements for violence prevention by The Joint Commission (TJC), effective Jan. 1, 2022. (For more information, see related story in this issue.)

To address an inevitable question, anecdotal accounts indicate the pandemic reduced violence in healthcare in 2020, due in part to widespread reductions in elective procedures and bans or limitations on visitors and family. Visitors are the cause of about 10%-20% of violence in healthcare, says Susan Scott, PhD, RN, CPPS, FAAN, a nurse scientist and violence researcher at University of Missouri Health Care.

“We haven’t looked at our data yet, so this is just gut instinct,” she says. “During the pandemic, many times we had limited visitors or no visitation at all. Just the sheer decrease in volume of people coming to visit the patient I’m sure has some kind of impact. They can get aggressive with the staff if they don’t like something that they see. They respond very emotionally, and many times physically, to the staff members.”

78% Assaulted in One Year

Querin’s research was based on a survey of ED personnel conducted during November and December 2019. They also solicited the aforementioned narratives from residents, attending physicians, and nurses about their experiences of abuse and violence. The researchers collected 123 responses, a rate of 46%.

Among all HCWs in the ED, 78% reported violent assault within the prior 12 months. In addition, 70% of respondents reported “multiple” incidents of verbal assault in the period. Verbal assault can quickly escalate into physical assault.

“A patient was verbally assaulting,” an emergency nurse reported in the survey. “After many minutes of being yelled at, the patient hit me and swung at another nurse, demanding IV pain medicine, then proceeding to scream that this was our fault, and threatening to kill us and our families.”1

Some residents expressed fear for personal safety while rounding in a poorly designed psychiatric triage unit. The unit was narrow, and the door locked behind them upon entry.

“Any time I go into the psych triage area, I feel unsafe,” a resident noted on the survey. “Once I am in there, there is no easy way to escape if I need to. And no way for others to get in easily.”

Another resident said “a patient became upset related to narcotics and threatened to kill staff. He was escorted out but only to the hospital front door. He was waiting in the ambulance bay when I got off work at 2 a.m. I had to quickly get back inside and call hospital police.”

Overall, 63% of respondents reported feeling unsafe. Nearly half said they had been asked to do something that made them feel physically or emotionally uncomfortable, Querin reported.

“On a daily basis, I was going in to evaluate individuals who were making a lot of comments that were kind of scary, in small spaces without a lot backup and security,” Querin said. “We have made some changes in our emergency department. EDs around the nation are also working on these kinds of things.”

As part of the changes, the psychiatric triage unit was completely redesigned, a safety committee was formed, and a better incident reporting system was implemented. The latter action was because, as has been widely observed, HCWs often do not report a violent incident because they feel nothing will be done about it. Only 20% of survey respondents said they filed an incident report. There is a sense of futility that sets in, contributing to burnout.

“Workplace violence is, unfortunately, part of the job,” a nurse indicated on the survey. “It’s concerning that charges can be filed against a healthcare professional for too much force, but nothing can be done when a patient punches, kicks, bites, scratches, pulls hair, or generally assaults you. I’m not here to get beaten up. This culture needs to change before a nurse gets killed by a patient.”

That comment was made before the improvements had begun. It looks like the new system will be needed to protect workers as patient volume rises again.

“The volumes more recently have picked up significantly,” Querin says. “Our psych population is getting heavier. We are seeing a lot of sick patients who have been experiencing COVID. I don’t know if the violence has increased, but we are definitely seeing a lot more volume and a lot more frustration.”

Peer Support

A violent incident can have a ripple effect, going beyond the HCW who is attacked to affect those who bear witness to the event. These so-called “second victims,” as well as the actual victim, can experience debilitating emotional systems that can be mitigated by peer support programs, a recent paper by Scott and colleagues at the University of Missouri showed.2

Originally, such programs were designed to aid HCWs after the death of a patient. But it became clear some time ago the same symptoms were seen in staff who suffered or witnessed violence against colleagues.

“The common element is that healthcare workers are emotionally traumatized by the experiences, often reacting with an acute stress reaction with physiologic responses and accompanying confusion, anxiety, grief, shame, guilt, and feelings of inadequacy,” Scott and colleagues reported.2

Between 2009 and 2019, the UM program documented 834 peer support interventions, 75 (9%) related to workplace violence. These included 57 one-on-one encounters and 18 group support sessions. In 2018-2019, the Missouri team experienced an increase in workplace violence, doubling to 20% of peer support team activations.

“My colleagues and I had a sense that violence was increasing in 2018,” Scott says. “The Joint Commission sent out a Sentinel Alert for healthcare facilities that April. That May, we really started full-fledged effort on what can we do to tackle this problem head-on. Peer support is not a [direct] antidote for workplace violence, but we have another group that is working on all kinds of mitigation factors to prevent violence.”

The ability to pause and process the moment with a trusted peer or co-worker has been proven through many research projects as an effective tool in the hospital’s arsenal for helping ensure their staff members’ psychological safety, Scott explains. Peers usually are experienced workers who have dealt with many personality types and possess a natural sense of empathy.

“They are individuals who, when everything breaks loose in the unit, they’re the steadfast, strong person,” Scott says. “We take peers with these interpersonal skills and with experience in the healthcare environment and then train them on working with individuals in crisis as well as offering them appropriate resources throughout the institution and even the local community.”

Sometimes, it is the victim of an attack who receives the peer support. Other times, a wider group of those involved and who witnessed the incident meet as a group.

“It could be four, five, six people from one emergency department who were all [involved in] the same case,” she says. “[It] is actually fairly helpful for the group to get together and talk about that lived experience and gain insights from each other’s perspectives. It strengthens them for the next encounter.”

In general, there are three outcomes for an HCW involved in a violent event, Scott explains.

“They could thrive, where they take the event and learn from it, and provide insights into how to make it better,” she says. “All of that is kind of healing and cathartic in a way for the caregiver. [They don’t want] the next patient or the next staff member to fall prey to the same issue that they suffered from.”

The second outcome is “surviving,” meaning the clinician continues to work but never returns to their pre-event baseline performance level.

“Many of them tell me that they do just enough to get the job done, but they don’t want to be vulnerable,” Scott says. “It’s like presenteeism. You go to work with a cold or a headache and you’re not quite there, but you’re doing your job. That’s what a survivor looks like.”

The third outcome is the “dropouts,” when workers leave their chosen medical field after a violent incident.

“That might be a nurse going from the emergency department to newborn nursery care, or it could be a clinical pharmacist who goes to pharmaceutical sales,” Scott says. “It could be a surgeon who goes from being the top clinical performer at the institution to doing bench research. The dropouts are the ones that I worry about, because those are the ones that if they would get support, then maybe we could have saved them to work in the jobs that they truly had passion for.”

The three classifications — thriving, surviving, and dropouts — do not necessarily predict the eventual success of that person’s professional career, she adds.

A case study in the paper describes a nurse who was a victim of attempted strangulation in a post-anesthesia care unit. The nurse was performing an assessment when the patient grabbed a pulse oximeter cord and began choking her. A second nurse helped break the patient’s grip, but the victim had marks around her neck and clearly was shaken. The peer intervention team counseled and assisted her. Initially, she seemed to recover from the attack.

“We’re lucky she did so well, but she questioned just being a nurse in orthopedics. She had been in surgery for a long time, and that was kind of the tipping point for her,” Scott says. “She actually left the facility and went to another hospital, though we had given her a lot of support in the aftermath of that event. However, within two years, the nurse returned, realizing she wasn’t getting that kind of support at the other facility.”

Historically, HCWs have performed their jobs and withstood the comments and physical attacks.

“For a long time, we’ve kind of accepted that kind of thing — the spitting, the violence that we’ve encountered,” Scott says. “Now, healthcare as an industry is really taking a stand. We need to treat each individual with respect, and there’s no room in healthcare for that kind of either verbal assault or physical aggression.”

REFERENCES

  1. Querin LB, Dallaghan GLB, Shenvi C. A qualitative study of resident physician and health care worker experiences of verbal and physical abuse in the emergency department. Ann Emerg Med 2021 Jun 22;S0196-0644(21)00302-4. doi: 10.1016/j.annemergmed.2021.04.019. [Online ahead of print].
  2. Busch IM, Scott SD, Connors C, et al. The role of institution-based peer support for health care workers emotionally affected by workplace violence. Jt Comm J Qual Patient Saf 2021;47:146-156.