Healthcare-related workplace violence has been an issue for a long time, but evidence is mounting suggesting COVID-19 pandemic-related stress and exhaustion have only made matters worse. Although healthcare workers have been hailed as heroes in some sectors, they also report episodes of verbal and physical assault while trying to care for frustrated, angry patients, many of whom feed on a daily diet of misinformation related to masks or vaccines.
Considering their prominent position at hospital entry points, emergency personnel are bearing the brunt of much of this violence. The good news is the problem is receiving more attention it deserves, with a panoply of robust solutions aimed at addressing the problem from several different angles.
Casey Clements, MD, PhD, has co-authored several recent studies on violence in healthcare. “Many of the people who work in healthcare know that this is one of the greatest threats within the healthcare sector. Nobody outside of healthcare necessarily knows what is going on with this despite the fact that OSHA has reported that 74% of workplace injuries from assaults by person have been in the healthcare sector,” explains Clements, ED clinical practice chair and staff safety officer, occupational safety, at the Mayo Clinic in Rochester, MN. “This research is an ability to shine a light on something, and then really, hopefully, start to move the needle in fixing it.”
Sarayna McGuire, MD, chief resident of emergency medicine at the Mayo Clinic in Rochester, MN, agrees addressing the growing problem of workplace violence in healthcare is vitally important. “I was a military police officer and served in Iraq back in the day. When I trained here [at Mayo], I naïvely thought that I was leaving a prior career in violence when I entered medicine. That was not the case, unfortunately,” she laments.
For a variety of reasons, McGuire argues many more healthcare workers likely are affected by violence than statistics would suggest. This is because only about 25% of staff go on to report incidents of violence they have experienced. Previous studies of the problem generally have focused solely on clinicians and nursing staff, according to McGuire. “They haven’t incorporated housekeeping or secretarial support or phlebotomists ... and the entire multidisciplinary healthcare team is experiencing this,” she explains.
McGuire, Clements, and colleagues were determined to correct this gap, and they did so in new findings first unveiled at the Scientific Assembly of the American College of Emergency Physicians in Boston in October.1 They presented the results of an anonymous survey of a multidisciplinary cohort of healthcare workers from 20 Midwestern EDs conducted between Nov. 18, 2020, and Dec. 31, 2020. Respondents shared what they had experienced in the six months before they were surveyed. Seventy-two percent of respondents indicated they had experienced violence during that period. Specifically, 71% reported verbal abuse, and 31% indicated they had been a victim of physical assault.
However, 77% of respondents indicated they rarely or never report such incidents, for several reasons: they did not sustain a physical injury (53%), violence is part of the job (47%), too busy (47%), and reporting is inconvenient (41%).
McGuire says the findings are representative of what clinicians on the front lines generally feel. “There is an unfamiliarity at institutions about how exactly to report these incidents,” she says. “The actual method of reporting within our health system is what we call the Employee Incident Reporting system; yet we found that only around 35% of respondents indicated [reporting events through] that correct method.”
Part of the problem is there are so many reporting systems for security, safety, and other matters. Staff often are not clear which system to use to report violence. They also are concerned about anonymity, according to McGuire. “Within our health system, we are working on targeted efforts to simplify the reporting process,” McGuire shares. “We recognize what our survey respondents are saying: it’s too complicated, it takes a lot of time ... and we need to make sure these reports are as anonymous as possible.”
Clements says the reporting problem reflected in survey responses is not unique to any specific health system or organization. “In healthcare, we have set up very robust systems to protect patients and to care for them in the way they need to be cared for,” he says. “COVID was a watershed moment because we realized we needed to feel safe at work to care for patients in a safe way as well.”
However, to make worker safety a priority, everyone must recognize violence and abuse should not be part of the job. “There is no bigger problem in healthcare than that mentality,” Clements says. “It is absolutely not somebody’s job to be assaulted when they are at work.”
When respondents were asked what they thought were the biggest contributors to workplace violence, 73% cited significant mental illness. Influence of alcohol also was cited by 73%, and 70% of respondents indicated the influence of illicit drugs was a significant factor. Other factors mentioned included a history of violence (57%), drug-seeking behavior (55%), prolonged wait times (37%), and crowding/high patient volumes (24%).
Other findings presented at the ACEP meeting indicated many more respondents had experienced verbal assault vs. physical assault. Still, 22% said their work was affected because they were a victim of workplace violence. Also, 48% reported workplace violence had changed the way they interact with or perceive patients, 21% reported experiencing symptoms of post-traumatic stress, and 18% said they have considered leaving their jobs.
There have been numerous anecdotal reports suggesting healthcare violence has worsened during the pandemic. In a single-center study, Clements and McGuire found more concrete evidence indicating this was the case.2
Although the numbers do not indicate why the violence increased, a high level of stress related to the pandemic might play a role. “Societal stress plays itself out in high-intensity situations, and EDs are high-intensity situations,” Clements says. “When you come to the ED ... you are under stress. Often times, you are getting bad news. People’s ability to cope with that [has] clearly not [been] adequate as they have taken it out on healthcare workers.”
Financial stress, social isolation, and substance abuse also could be to blame. “We have shown that the rate of ED visits related to alcohol use has gone up during the pandemic,” Clements says. “I think that is going to continue to be a problem for years to come.”
Healthcare leaders must find better ways to address this issue on several fronts. “You have to build systems to prevent, mitigate, and respond to violent events. That is not something that places have put as much strong effort or resources into as is probably necessary,” Clements observes. “Also, these are people from our communities who are going into a healthcare setting and perpetrating these acts of violence. We can’t solve this alone, internal to the healthcare organizations. We have to go outside our walls to see how we fit into communities and how we interact with society.”
Further, Clements says it is important for ordinary citizens to know about this problem and to view it as unacceptable. “When you don’t think about it, and it is behind a closed door, it seems like it is acceptable,” he says. “If we change the way society thinks about how they interact with healthcare, how the healthcare workers are there to help [patients], not to be a subject of abuse, harassment, or violence, then that is really the ultimate [way] to prevent it.”
To that end, Mayo has developed a community collaborative that includes internal leaders along with community leaders, law enforcement, social workers, and others. “It is imperative that we keep that community collaborative going, sit down with them, and continue to work out ways to mitigate these risks,” McGuire says.
Other steps to consider include making physical changes in the spaces used to care for patients. For example, leaders must think about where clinicians are located in a room to designate an egress spot. “Then, we have to have a reliable and robust response for when things do happen to support [a healthcare worker], both in the moment and then in the aftermath of [a violent] event,” Clements says.
Clements suggests these efforts should include support from legal and mental health experts. Additionally, providers should feel safe to come back to work without any victim-blaming.
Healthcare systems should provide more training so providers feel more prepared to handle verbal or potential physical assaults. “In medical school, I did not receive any training on anticipating a violent patient or how to address being in a violent encounter. I don’t think my experience is unique,” McGuire shares.
Clements echoes these sentiments, noting he has been working in occupational safety for at least seven years and has never received any de-escalation or physical safety training. “We were really surprised to learn how environmental services personnel are abused, how the people who answer the phones in the clinic for appointments are routinely abused and yelled at, and how radiology techs are physically assaulted,” Clements reports. “Even we who have worked on this were surprised to learn how ubiquitous this culture of abuse, harassment, and violence has become in healthcare.”
McGuire says the time is now for the industry to become more proactive. “That’s in terms of training the entire multidisciplinary team on ways to address a violent encounter,” she says. “Moving forward, we also need to do more on our part to partner with other institutions. Right now, mitigation efforts are very localized, institution to institution.”
The Mayo Clinic is working on making both de-escalation and physical safety training accessible to all staff. Leaders also are focused on building a system of reporting and measurement that is simple, reliable, and supported by people other than just the victim when something happens. “We need to bring in resources to lift the burden of reporting, the busywork and paperwork, off the shoulders of someone who has already suffered through a horrific event,” Clements says.
- McGuire S, Finley J, Gazley B, et al. Workplace violence reporting behaviors in emergency departments across a health system. Ann Emerg Med 2021.
- McGuire SS, Gazley B, Majerus AC, et al. Impact of the COVID-19 pandemic on workplace violence at an academic emergency department. Am J Emerg Med 2021 Sep 23;S0735-6757(21)00782-8. doi: 10.1016/j.ajem.2021.09.045. [Online ahead of print].