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Hospitals fall short in preventing violence
Studies look for impact of programs
Many hospitals are failing to address the risk of workplace violence, even when state law requires prevention efforts, according to preliminary findings of a California-based study.
In California, hospitals must have a violence prevention program in order to receive accreditation by the state licensing division. But those programs often fall short, says researcher Corinne Peek-Asa, associate professor of occupational health at the University of Iowa’s Injury Prevention Research Center in Iowa City.
She is conducting interviews in 200 California hospitals for the ongoing, three-year project, which is designed to assess violence prevention activities and the impact of the California law. The project is sponsored by the National Institute for Occupational Safety and Health (NIOSH) in Cincinnati. "Some hospitals have very good, very comprehensive security programs. It’s clear that the administration is prioritizing the issue. Other hospitals have not recognized the problem. [There are some] hospitals that really do have a high level of violence but have not addressed it yet," she adds.
Peek-Asa stresses that a security plan is not the same as violence prevention. In its Guidelines for Preventing Workplace Violence for Health Care and Social Service Workers, the U.S. Occupational Safety and Health Administration (OSHA) outlines the components of a Violence Prevention Program: management commitment and employee involvement; work site analysis; hazard prevention and control; and safety and health training.
Yet there is no single template. "It starts with a good comprehensive plan, where there’s some forethought into this based on the actual environment the employee works in — how patients flow through procedures, how information is communicated among different workers or shifts."
The need is clear: Nurses and nurses’ aides have among the highest rates of workplace assault of all occupational groups. In 2000, there were 2,831 assaults in hospitals nationwide that resulted in a health care worker missing at least one day of work, according to the U.S. Bureau of Labor Statistics.
The number of nonreported assaults is far greater, says Susan G. Gerberich, PhD, director of the Regional Injury Prevention Research Center and Center for Violence Prevention and Control in the School of Public Health at the University of Minnesota in Minneapolis. Even verbal assaults have a significant impact. "There are numerous consequences from those physical assaults. There are even more consequences from the nonphysical — verbal abuse, sexual harassment, threats. That kind of thing should not be tolerated," she says.
It’s part of the job’
One major barrier to violence prevention comes from the nurses and other health care workers themselves: Too often, they accept violence as an expected part of their jobs.
That mindset may come from the top, at least in the workers’ eyes. In one study, two-thirds of nurses who had filed workers’ compensation claims related to violent assaults at work said they felt the hospital administration considered assault to be "part of the job."1
"I think [administrators] have to make it very clear to the employees that they want to do everything in their power to prevent and control these violent events," says Gerberich. In fact, administrators may not realize the extent of the problem in their facilities, in part because of those attitudes and perceptions. "There’s a great hesitancy on the part of nurses to even report some of these events." Getting reliable baseline information about violent events is an important first step toward violence prevention, she says.
Administrators could convene a multidisciplinary task force and use outside contractors to solicit information from employees. "It’s an extremely sensitive issue," Gerberich says.
Meanwhile, in the push for patient safety, administrators need to be careful not to send a subtle message that workers are expendable. "The new emphasis on good patient and customer relations focuses so much on the patient satisfaction and the patient experience that it leaves behind the worker experience. We believe those go hand in hand," says Peek-Asa. "You can’t sacrifice the worker for the patient."
Even if a hospital has addressed violence prevention, it needs to send a consistent message. Simply stating that you have "zero tolerance" for violence isn’t enough, she says.
Does violence prevention work? Researchers are beginning to ask that question — and to evaluate what aspects are effective.
Last year, NIOSH awarded five grants totaling about $1.8 million for research into violence prevention. Health care workers were among four occupations targeted by the research as high risk.
In research at the University of Minnesota, the presence of security personnel and video monitors were related to lower rates of work-related assaults.
Written policies on assault prevention and dealing with patients with repeated violent behavior also were linked to less violence. While the nurse-patient ratio wasn’t a significant element, working alone or working with patients with mental illness were related to higher rates of assault.1
"There’s no one factor that is directly related," says Gerberich. "It’s in concert with other factors in the environment. Patient contact is certainly very important, but that’s also controlling for the environment in which they’re working. You can’t just look at one variable at a time." Quality leadership is also "crucial" in creating effective violence prevention, she says.
Both Gerberich and Peek-Asa say they hope further research will shed light on the essential elements of successful violence prevention.
In her research, Peek-Asa plans to compare hospital prevention programs in California with those of other states. For example, California requires all employees in the emergency department to have training in how to de-escalate growing violence. Researchers also hope to quantify the benefits of violence prevention, which include lower workers’ compensation costs, less absenteeism, greater work satisfaction, and increased productivity, she says.
"One problem is that we haven’t demonstrated how effective prevention can be," Peek-Asa says. "There can be extremely effective approaches to preventing violence."
1. Lee SS, Gerberich SG, Waller LA, et al. Work-related assault injuries among nurses. Epidemiology 1999; 10:685- 691.