Hospitals must address risk of violence at the workplace

Incidents trigger OSHA citation, Joint Commission alert

Hospitals have been placed on notice: They must address the hazards of workplace violence.

In a Sentinel Event Alert, The Joint Commission accrediting body reminds hospitals of the requirements to maintain a written security plan, conduct risk assessments, develop prevention strategies, and maintain a response plan that would be implemented if there is a violent incident. Although the alert relates to violence against patients, the preventive measures would encompass risks to health care workers as well.

In response to complaints from nurses — and a shooting that seriously injured a nurse — the U.S. Occupational Safety and Health Administration (OSHA) issued a rare "general-duty clause" citation to Danbury (CT) Hospital related to workplace violence.

Although OSHA does not have a standard related to workplace violence, the agency said, "The employer did not furnish employment and a place of employment which were free from recognized hazards that were causing or likely to cause death or serious physical harm to employees in that employees were exposed to fatal or serious physical injuries from violent patients." Employers have a "general duty" to maintain a workplace that has no serious hazards to workers.

"I think it should be a wake-up call to hospitals and other health care organizations that they can't deny the issue any longer," says Jane Lipscomb, FAAN, PhD, RN, professor in the Schools of Nursing and Medicine and director of the Work and Health Research Center at the University of Maryland Baltimore.

In 2008, 2,250 hospital workers had injuries from assaults that were serious enough to require days away from work or restricted days, according to the U.S. Bureau of Labor Statistics. That actually represents a slight increase from 2006 and 2007.

Violence in hospitals also represents a hazard to patients and visitors, notes Lipscomb. "We really need to look at protecting everyone who is part of [the hospital] community," she says.

Shooting follows other assaults

Violence isn't just a problem for hospitals in urban settings or high-crime communities. Incidents occur at community hospitals, in rural or medium-sized cities. Violence relates more to the stresses of the health care experience – such as long waits or inadequate communication – or with facility access and security than with the locale, says Russell Colling, MS, CPP, CHPA, a health care security consultant based in Salida, CO, who works with The Joint Commission.

Nurses at Danbury Hospital had expressed concerns for many years about verbal and physical assaults from patients, says Mary Consoli, RN, BSN, president of the Danbury Nurses Union, Unit 47 (the American Federation of Teachers Local 5047).

One primary problem: the psychiatric unit is located on two floors, requiring employees to get into an elevator with mentally unstable and sometimes aggressive patients. The hospital, including treatment areas of the Emergency Department, was too accessible, says Consoli.

On the last day of December in 2008, a psychiatric patient lunged at a nurse, striking her. Less than a month later, a patient threatened to throw a nurse down the stairs. In May 2009, a security guard was beaten by a patient in the psych unit. In October, a psychiatric patient punched a nurse in the jaw, causing her to lose her balance, fall, and break a hip.

"That was the last straw," says Consoli. The union filed a complaint with OSHA as well as the Connecticut Department of Public Health.

Typically, OSHA sends advisory letters if inspectors have concerns about how a hospital is addressing the hazard of workplace violence. The agency has voluntary guidelines but no standard that governs the issue.

But in March 2010, while OSHA was still investigating, an elderly cardiac patient pulled a handgun from beneath his hospital gown and began firing. A nurse who was a former Marine saw the gun and was able to prevent him from harming others nearby. The nurse was shot three times before security guards wrestled the gun away.

The incident got OSHA's attention. The citation notes that in the past five years, there have been 25 cases of violence with injuries that involved lost workdays or restricted work. "OSHA felt in this case, [the overall situation at Danbury Hospital] did rise to the level of a violation and did warrant a citation," says Ted Fitzgerald, spokesperson for OSHA Region 1, which encompasses New England and New York. OSHA fined the hospital $6,300.

The hospital did not appeal the citation. It conducted a security review and began to adopt changes, such as limiting hospital access, requiring visitor passes, and beefing up security. "We have already begun to implement that [security] plan," hospital spokesperson Andrea Rynn said in a written statement. "We are fully committed to creating an even safer, more secure workplace for our employees, patients and visitors."

Nurses fearful of violence

At the time of the shooting, the nurses' union had already begun soliciting responses from nurses to a survey about workplace violence. One in four (27%) said they had experienced threats of assault in the past year. Almost half (47%) had been sworn at or otherwise verbally insulted (40%). About one in seven (15%) said they had experienced physical assault in the past year.

Sixty-nine percent said they did not feel protected from violence at work. In comments, many written after the shooting incident, nurses cited concerns about staffing and security.

"People come in from all walks of life, and they're very abusive," says Consoli. "They may be under the influence of alcohol or drugs. They're under stress. They react with violence."

The shooting was unusual because it occurred on the cardiac floor and involved an 85-year-old patient — not a common or expected scenario. But perhaps it underscored that violence doesn't necessary follow stereotypical patterns.

"People [at other hospitals] are starting to look at their policies and procedures in light of what's happened at Danbury," says Consoli. "People are looking and saying if this can happen here, it can happen anywhere."